Understanding & Managing
Biochemical & Co-occurring Disorders
A majority of mental, behavior, and addiction disorders such as anxiety, schizophrenia, attention deficit or hyperactivity disorder (AD/HD), borderline personality disorder, and bipolar depression can be caused by imbalances in chemical substances called neurotransmitters, in addition to stressful events, genes, and adverse childhood experiences (ACE). When a psychiatric disorder exists with a substance use disorder, it is referred to as a co-occurring disorder or comorbid disorder. The brain is a chemical factory that constantly produces dopamine, serotonin, GABA and other required neurotransmitters throughout our lives. The raw materials for these processes are amino acids, vitamins, minerals, and other nutrients. In essence, nutrients are the sources of our neurotransmitters that help to regulate brain chemistry (Walsh, 1997).
Imbalances in biochemistry, such as developmental, learning or behavior disorders, and mental illness include, anxiety, ADHD, schizophrenia, autism, depression, violence and criminal behavior. Our society often attaches a stigma to those with emotional or mental disorders, but, in reality, the vast majority that suffers from these disorders are more like the rest of us than they are different (Amen, Making a Good Brain Great, 2006).
Approximately 40 percent of persons diagnosed with a psychiatric disorder have a co-existing substance abuse or dependence disorder (Horsfall, Cleary, Hunt, & Walter, 2009). Individuals with addiction disorders frequently suffer from an assortment of vitamin and mineral deficiencies, maladaptive and co-occurring disorders, and depression among other problems. Adequate nutrients to produce neurotransmitters can usually be obtained from a well-balanced diet involving the major food groups. However, many persons, including those with psychiatric and substance use disorders, have poor diets or absorption and metabolic disorders, which result in poor health from vitamin and mineral deficiencies and severe nutrient imbalances that adversely affect brain functioning (Walsh, Glab, & Haakenson, 2004).
For example, animal studies have shown that a diet low in vitamin B-6 is a vital cofactor required for natural synthesis of serotonin (Dakshinamurti, et. al., 1997). Serotonin is an inhibitory neurotransmitter that has been found to be intimately involved in emotion and mood. Too little serotonin has been shown to lead to depression, problems with anger, control, obsessive-compulsive disorder, and suicide. Adequate serotonin is important for a restful night’s sleep as the body converts serotonin into melatonin at night-time. The relationship between diet and behavior takes us into a vast area that is well worth investigating. Here, we will only discuss a few of them.
Our nutritional and biochemical health influences our mood and cognition, which can lead to various maladaptive behaviors. Dr. Daniel Amen, a psychiatrist who has conducted more SPECT brain scans than anyone has worldwide, explains that certain imbalances may lead some people to turn to an addictive substance in an attempt to feel better (self-medicate). Some may use “uppers” such as cocaine, caffeine, and methamphetamine's to stimulate underactive areas of the brain. While some use “downers” such as marijuana, alcohol, sedatives, or pain killers to calm and medicate hyperactive brain systems. Unfortunately, these substances are both harmful and addictive, and can cause brain damage, even permanent damage and are no medication at all.
For example, attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD), is a complex brain disorder with decreased activity in the prefrontal cortex (PFC). The harder an ADD person tries to concentrate, the less brain activity s/he has to work with. Brain expert, Amen expounds, "Many attention deficit disordered persons will try to self-medicate with stimulants to increase brain activity in the PFC. They also tend to self-medicate using conflict seeking behavior. If they can get someone upset, it helps to stimulate their brain by producing norepinephrine (adrenaline), a powerful stimulant. They can become dependent on those emotions because of the stimulation it provides, regardless of who they engage in a conflict with. Of course, this is unconscious brain-driven behavior. However, this conflict seeking behavior is apparent for those who have been around an ADD or ADHD person long enough (Amen, Healing ADD, 2002).
Many people undermine the seriousness of ADD disorders. If left untreated ADD can affect a person’s abilities, such as self-esteem, learning abilities, social relationships, work, and lead to greater problems. Studies show that persons with ADD use twice as many medical treatments than persons without ADD. Up to 35 percent of untreated ADD teens never finish high school, up to 50 percent of untreated ADD teens and adult’s abuse substances and all tend to be defiant.
ADD and ADHD are highly treatable disorders. There are different treatments for different types of ADD. Exercise, a high protein and a low carbohydrate diet is extremely helpful, in addition to the right supplementation including omega 3 fatty acids. (Amen, Healing ADD, 2002). Mental imbalances and substance abuse disorders are often caused by deficits in a complex interchange of nutrition, biochemistry, exercise, coping skills, genetic makeup, environmental stressors, and more. Sufficient nutrients to modulate neurotransmission and regulate brain chemistry can usually be achieved from a nutritionally rich diet, proper neuronutrient supplementation, and a limited consumption of processed, refined, and sugary foods.
DHA (docosahexaenoic acid) from omega 3 fatty acids is an essential element for growth and development of the brain of infants and is also a requirement for the maintenance of normal brain function in adults. Omega 3 essential fatty acid makes up 20 percent of the human brain and nervous system. Deficiencies in DHA are linked to learning problems, ADHD, and unipolar depression. The connection of DHA deficiency to depression is the reason for the strong association between depression and heart problems, especially myocardial infarction. Many studies have been done on the benefits of DHA. Research indicates that when adults consume omega 3’s from cod liver oil, they have less joint stiffness, more flexibility, and greater mobility.
DHA is particularly important to developing children and to pregnant and lactating women; which plays a significant role in normal long-term physical and mental development of the fetus, including brain, eye, immune and nervous system. DHA provides mood and nerve support for children, adults and pregnant or nursing mothers. Studies found that those women who consumed larger amounts of fish suffered nearly half the rate of postpartum depression than those who consumed little or no fish. Research has even shown that children of women who took a DHA supplement from cod liver oil during pregnancy and while lactating had higher IQ’s at age four than children whose mothers had taken a placebo. Though very important for proper functioning, DHA is not produced by the body and must be obtained through diet and/or supplementation.
Young adolescents with severe behavioral problems aged 10-16 recorded a 68% reduction in violent behavior when eating a healthy diet along with a fish oil supplement. In a study, teenagers aged 15-16 years and attending a school for the behaviorally challenged were given fish oil for 12 weeks prior to taking a standardized test. On average, they surpassed their predicted results by one grade level. Another study showed that 15-year old males who ate fish at least once a week had higher cognitive skills at age 18 than those who ate fish less frequently (Benton, 2007).
Three different studies conducted in 1996, 1999, and 2000 among college students demonstrated that DHA supplementation reduced elevations in aggression and hostility in response to psychological stress. The EPA and DHA in fish oil support neurological function, balanced moods, stress management, healthy circulation, and balanced blood sugar levels. GLA, a beneficial omega-6 fatty acid, supports healthy skin, hair, joints, hormonal balance, and provides a “feel good” effect that improves mood. The mood stabilizing effect of omega-3, especially DHA, is also suggested as therapeutic supplement for the prevention and treatment of various psychiatric disorders. Supplementing the diet with DHA can positively affect both physical and mental functioning (Walsh, 2005).
A study showing that phospholipids influence behavior performed on a group of young boys, half with low fatty acid measures, showed that behavior problems were significantly higher in the study group with the lower acid levels. Greater number of health and learning problems occurred in the lower level group as well. Research spanning a period of 20 years has revealed abnormal trace metal concentrations in violence prone young males 3-20 years of age (Walsh, Glab, & Haakenson, 2004).
A lengthy study undertaken at Yale University focused on a number of factors influencing mood and depression, among them the direct effect of tryptophan and folic acid deficiency in treating the symptoms of depression. The review also supports evidence that proper nutrition, the content of meals in terms of protein and carbohydrate content, has a definite effect on mood and performance in humans. These studies examine the essential amino acid L-tryptophan and the role it plays in the biochemistry of sleep. It suggests that tryptophan may be a useful treatment in mild cases of depression and in cases of bipolar disorder resistant to standard treatment (Boman, 1998).
Like substance use disorders, a majority of psychiatric and behavior disorders such as depression, bipolar, anxiety, schizophrenia, and ADHD can be linked to stressful events and ACE, in addition to imbalances in chemical substances (Walsh et al., 2004; Benton, 2007). Anxiety disorder, for instance, is multi-factorial and frequently co-occurs with substance abuse disorders. Anxiety disorders appear to be caused by an interaction between biopsychosocial factors, including genetic vulnerability. These factors cause a response to situations, traumas, or stressors producing clinically significant anxiety disorders. Environmental stressors, such as early childhood trauma, abuse, and a disordered home life, clearly play a role in the risk for developing anxiety disorders to varying degrees (Yates & Bienenfeld, 2014; NIMH, 2014).
The brain is the master regulator and fundamental organ in response to stress because it perceives possible danger and determines behavioral responses. Stress involves a two-way message between the brain and body systems by way of neural and endocrine mechanisms. Stress hormones protect the body from acute stress in daily life and promote adaptation, which is known as “allostasis”. Over time, however, chronic stress can lead to the “allostatic load” placing wear and tear on the body that produce alterations in brain functioning causing neurons to maladapt (McEwen, 2007, p. 880-881).
The emergence of literature in the field of psychiatric epigenomics has provided insights into the negative consequences of ACE and early life stress (e.g. children exposed to abuse and neglect), and the consequences of physical health and cognitive development as well as the importance of adaptation. Childhood trauma appears to have lasting effects on brain regions that alters mood and anxiety-related behaviors as well as cognitive function. To illustrate, McEwen (2008) noted that early life experiences prompt lasting patterns of stress and emotional responses that influence physiology, behavior and brain function. The prefrontal cortex, hippocampus, and amygdala endure stress-induced structural alterations, which subsequently restructures behavioral and physiological responses increasing the risk for various mental disorders (McEwen, 2007, p. 890-891).
Although a stressful environment clearly plays a major role in mental health outcomes, additional factors should not be overlooked. McKim and Hancock (2012) discussed that genetics control physiological factors including aspects of body chemistry, brain function, and personality that increase the risk of psychiatric illness or the probability that a person will abuse alcohol in particular settings (p. 151). Many psychiatric and neurological disorders are not due to mutations in a single gene, but involve molecular disruptions necessitating multiple genes and signals that control their expression. Recent evidence for the existence of sustained epigenetic mechanisms of gene regulation in neurons have been implicated in mediating complex behavior by means of long-term changes in gene expression. This includes psychiatric disorders such as depression, schizophrenia, anxiety, and drug addiction (Tsankova, Renthal, Kumar, & Nestler, 2007, p. 355).
Epigenetics research explores the ways wherein environmental factors alter the way genes express themselves. For instance, the short form of the serotonin transporter is linked with several conditions including alcoholism. Thus, individuals who have this allele are more at risk to respond to stressful situations by developing depressive syndromes. Therefore, the importance of identifying the sensitivity of gene-environment interactions in comorbid disorders should be considered (McEwen, Importance of gene-environment interactions section, 2008).
Addiction disorders and psychiatric disorders are understood using a biopsychosocial model. Therefore, these disorders are not singularly determined by environmental factors or what genes we inherit, but also gene expression—and that is influenced by factors that are in our control: diet, exercise, lifestyle, psycho-social-emotional influences, and coping and adaptive abilities. Understanding the numerous causes of comorbid disorders can add value to clinical practice by helping clinicians ask more appropriate questions, facilitating a more thorough and accurate diagnoses, while assessing causal brain systems pathology and improving patient compliance (Amen, Willemier, & Johnson, 2012).
Additionally, the fascinating new science of “epigenetics” helps to identify genetic variations that are known to contribute to the vulnerability of stressors, which has been recognized as being involved in developmental syndromes. Moreover, identifying brain trauma and toxicity in process addictions may be a significant contributor in treatment failure. Studies have shown that an integrated verses a parallel approach in the treatment of co-existing severe mental illness and substance use disorders enhanced effectiveness of treatment and decreased the use of crisis-related services (Mangrum & Spence, 2006).
Social and behavioral interventions that promote regular physical activity in conjunction with social support and a healthy diet and lifestyle have a significant impact on brain function and development throughout the life span that can counter and even prevent the harmful impacts of chronic stress. Consequently, modifications to the psycho-social-emotional environment can additionally ameliorate behavior while benefiting both the body and brain. The goal is to identify vulnerabilities to genetic and environmental stressors and utilize interventions that are likely to be most effective in early life intended to prevent severe conditions and promote healthy mental and physical development, or implement integrated methods designed to address these conditions in later life.
Amen, D., Willemier, K., & Johnson, R. (2012). The clinical utility of brain SPECT imaging in process addictions. Journal of Psychoactive Drugs.
Amen, D.G. & Burnett, L. (2012). The Impact of Brain Imaging on Psychiatry and Treatment for Improving Brain Health and Function, Alternative Therapies . Vol. 18, No. 2, 52-58.
Benton, D. (2007). The impact of diet on anti-social, violent and criminal behavior. Neuroscience & Biobehavioral Reviews, 31(5), 752–74.
Boman B. (1988). L-tryptophan: A rational anti-depressant and a natural hypnotic? Aust N Z J Psychiatry; 22(1)83-97.
Domschke, K. & Zwanzger, P. (2008). GABAergic and endocannabinoid dysfunction in anxiety - future therapeutic targets? Current Pharmaceutical Design, 14(33), 3508-17.
Hagedorn, W. B., & Hartwig Moorhead, H. J. (2010). The God-shaped hole: Addictive disorders and the search for perfection. Counseling & Values, 55, 63-78.
Horsfall, J.1., Cleary, M., Hunt, G.E., Walter, G. (2009). Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): a review of empirical evidence. Harv Rev Psychiatry, 17(1), 24-34. DOI: 10.1080/10673220902724599.
Hurd, YL (2006). Perspectives on current directions in the neurobiology of addiction disorders relevant to genetic risk factors. CNS Spectrums, 11(11), 855-64.
Kahan M, Srivastava A, Wilson L, Gourlay D, Midmer D. (2006). Misuse of and dependence on opioids: Study of chronic pain patients. Canadian Family Physician, 52(9), 1081-7.
Mangrum, L.F. & Spence, R.T. (2006). Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders. Journal of Substance Abuse Treatment, 30, 79– 84.
McEwen, B.S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87(3), 873-904. DOI: 10.1152/physrev.00041.2006.
McEwen, B.S. (2008). Understanding the potency of stressful early life experiences on brain and body function. Laboratory of Neuroendocrinology, 57(2), S11–S15.
McKim, W.A., & Hancock, S. (2012). Drugs & Behavior (7th Edition). Pearson HE, Inc. Page 151. Kindle Edition.
National Institute of Mental Health (2014). Anxiety disorders. Retrieved from http://www.nimh.nih.gov/health/topics/anxiety-disorders.
Rowney, J., Hermida, T., & Malone D. (2010). Anxiety disorders. The Cleveland Clinic Foundation. Center for Continuing Education. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/anxiety-disorder.
Stevens, P. & Smith, RL (2013). Substance abuse counseling and theory: The Merrill counseling series. Upper Saddle River: Pearson Education, Inc.
The American Academy of Experts in Traumatic Stress (2014). Effects of Parental Substance Abuse on Children and Families. Retrieved from http://www.aaets.org/article230.htm.
Tsankova, N., Renthal, W., Kumar, A. & Nestler E.J. (2007). Epigenetic regulation in psychiatric disorders. Nature Reviews Neuroscience 8, 355-367. DOI:10.1038/nrn2132.
Walsh, W. (2005). Biochemical individuality and nutrition. Retrieved from http://www.walshinstitute.org/biochemical-individuality--nutrition.
Walsh, W.J. Glab, L.B. & Haakenson, M.L. (2004). Reduced violent behavior following biochemical therapy. Physiology & Behavior, 82(5), 835-839.
Yates, W.R., Bienenfeld, D. (2014). Anxiety disorders treatment & management. Retrieved from http://emedicine.medscape.com/article/286227-treatment.
Yates, W.R., Bienenfeld, D. (2014). Anxiety disorders. Retrieved from http://emedicine.medscape.com/article/286227-overview