Shifting Paradigms: Chronic Lyme Disease Presenting as Primary Psychiatric Illness. Nancy L Brown MD Integrative Psychiatry Institute

Transcription

1 Shifting Paradigms: Chronic Lyme Disease Presenting as Primary Psychiatric Illness Nancy L Brown MD Integrative Psychiatry Institute

2 Copyright 2018 by Integrative Psychiatry Institute. All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the publisher. Integrative Psychiatry Institute 5420 Arapahoe Rd. Unit 1 Boulder, CO 80303

3 Learning Objectives At the end of this hour, you will be able to Discuss the incidence of chronic Lyme disease in psychiatric populations Recognize symptom patterns associated with chronic Lyme disease Use a screening tool to identify patients who may have Lyme disease Administer an appropriate diagnostic test for Lyme disease Establish an appropriate referral network for patients with probable Lyme disease

4 Case Presentation 28 y.o medical student Onset of severe depression in third year Continued intermittent depression x 30 years Emergency surgery at age 58 2 mos post-op: Sudden onset suicidal depression Within 6 mos: Progressive fatigue and cognitive dysfunction 2 ½ years later, diagnosed with chronic Lyme Disease and Babesiosis

5 Three Central Points 1. Chronic Lyme Disease often presents primarily as a psychiatric illness 2. Pattern recognition is essential in diagnosis 3. No training in medical school

6 The CDC and the IDSA (Infectious Disease Society of America) do not acknowledge that Chronic Lyme Disease exists Four studies (only 4!) sighted as proof of non-existence All significantly flawed in design and execution o Small sample size o Significant selection bias o Sub-therapeutic dosing and length of treatment Proof that Chronic Lyme and Co-infections do exist: o 301 published articles in the medical literature with evidence of persistent infection Wormser PG et al The Clinical Assessment, Treatment and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babebiosis: Clinical Practice Guidelines by the Infectious Disease Society of America CID :

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8 Lyme Disease: There are always multiple infections Borrelia bergdorferi (Lyme) omigrating joint pain Other Borrelia species Coinfections: Bartonella o Chronic pain o Severe anxiety Babesia o Severe depression o Heat and/or cold sensitivity Others o Mycoplasma, Chlamydia, Anaplasma, Ehrlichia

9 Prevalence of Lyme Disease CDC o Surveillance rate: 30,000 new cases a year o Underreported by a factor of 10:1 300,000 new cases Boltri and Hash o Underreported by a factor of 40:1 1,200,000 new cases a year Percentage of cases that become chronic: 34-62% Shadick NA, et al., The long-term clinical outcomes of Lyme disease. A population-based retrospective cohort study. Ann Intern Med. 1994;121(8): Asch ES, et al., Lyme disease: An infectious and postinfectioussyndrome. J Rheumatol. 1994;21(3): Boltri JM, et al., Patterns of Lyme Disease diagnosis and treatment by a family physician in a southeastern state. J Comm Health 2002:

10 Lyme Endemic Areas High to extremely high risk of exposure: o North East/Mid-Atlantic o Upper Midwest/Great Lakes o Pacific Northwest/No. California o Europe o Australia Moderate to significant risk of exposure: o Southeast o Eastern Great Plains o Intermountain West Low risk: o Desert Southwest

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12 Prevalence in psychiatric populations Review of the literature shows: o Between 30% to 80% + serologic testing for Lyme/Coinfections Estimated prevalence in 3 functional practices: 30 to 50% Over 400 peer reviewed articles document neuropsychiatric sx caused by Lyme Pathophysiology detailed by Bransfield Bransfield, RC Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist s Clinical Practice. Healthcare (Basel) Aug 25;6(3). Hájek T, et.al Higher prevalence of antibodies to Borrelia burgdorferi in psychiatric patients than in healthy subjects. Am J Psychiatry Feb;159(2):

13 How to recognize Lyme Disease in a Psychiatric Patient Population Practical Guidelines 1. A screening tool 2. A diagnostic test 3. Referral network

14 Look for these four major symptoms 1. Fatigue 2. Cognitive dysfunction 3. Chronic pain 4. Psychiatric illness Depression Anxiety 32% to 86% Mood swings/irritability 47% to 66% Rage/ODD Bipolar 37% to 98% incidence in Lyme patients Bransfield, RC Neuropsychiatric Lyme Borreliosis: An Overview with a Focus on a Specialty Psychiatrist s Clinical Practice. Healthcare (Basel) Aug 25;6(3).

15 Psychiatric indicators of possible Lyme Disease Early onset (pre-puberty) Consider in-utero transmission Absence of personal or family history Poor/paradoxical response to medications Excessive side effects/sensitivity to medications New onset or sudden worsening w/o psychological precipitants Especially after geographic exposure to Lyme endemic area Or exposure to a known trigger Fallon BA, et al, Am J Psychiatry Nov;151(11):

16 Your main screening tool: The Multi-Symptom Questionnaire Based on the combined work of Joseph Burascano MD, and Richard Horowitz MD o 73 symptom questions covering 11 systems in the body o 17 pattern recognition questions Do further testing for Lyme when: o Adults and teens: 24 symptoms are positive o Before puberty: 12 symptoms are positive For downloadable PDF: Contact me at nbrown6439@gmail.com

17 Other functions of the Questionnaire 1. Patients tend to minimize symptoms Focused on psychiatric illness Often discount or deny physical symptoms Use the instruction sheet! 2. Can be used to identify common co-infections or co-morbidities Common sx are noted for: Babesia Bartonella Mold Toxicity

18 Mold Toxicity often overlaps with Chronic Lyme Disease My practice: 80% overlap Commonalities: o Multi-symptom/multi-system illness o Very similar symptom profiles Theory: Co-existing genetic anomalies conferring risk for both 1. High risk HLA-DR genes 2. Methylation SNPs (Single Nucleotide Polymorphisms) Particularly COMT, MAO, and CBS

19 Other clues that your patient may have Lyme History of: o Tick attachment o Bullseye rash o Treatment for acute Lyme Disease in the past Currently accepted treatment for acute Lyme disease is only effective in preventing chronic illness in less than 20% of patients.

20 Onset or worsening symptoms after a triggering event Long periods of near dormancy are common Onset of sx may be far distant in time and place from the original infection Theory: o A robust immune system can control the infection o An event that compromises immune function can lead to activation

21 Onset or worsening symptoms after a triggering event Two most common triggers: 1. Mold! o Case presentation 2. Hormonal changes: o Pregnancy o Menopause Also look for onset after: Significant psychological or physical stress/trauma o Case presentation Severe illness Exposure to steroids (surgery)

22 Additional Clues Worse or better in specific situations After antibiotics Case presentation Low oxygen environments o Worse at high altitudes o Worse after prolonged flights Case presentation Co-morbid conditions o Fibromyalgia/regional pain o Chronic fatigue syndrome o Mold Toxicity o Multiple chemical sensitivity o Autoimmune disorders, especially RA, MS o Flouroquinolone Toxicity

23 How to recognize Lyme Disease in a Psychiatric Patient Population SUMMARY

24 Consider Lyme Disease in all of your patients with: These diagnoses: Chronic anxiety Chronic depression Bipolar illness ODD/rage/irritability These symptoms: Fatigue Brain fog Chronic pain And/or these characteristics: Treatment resistance! Early onset Sudden onset or worsening Exposure to a Lyme endemic area Lack of personal or family psych history Excessive side effects/sensitivity to meds

25 Diagnosis These organisms are extremely difficult to find (and treat)! o Stealth Organisms o Evade and suppress the immune system Standard antibody tests done by LabCorp/Quest/hospitals o Estimated 50 to 75% false negative results o Current legislation in 3 states labs must send a letter stating: A negative result does not mean you do not have Lyme Disease

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27 One of the most accurate tests IgM and IgG for Borrelia done by an independent lab - $250 out of pocket With proper interpretation, up to 85% accuracy Interpretation guide in support materials Alternative for patients who cannot afford an out of network lab LabCorp or Quest Western Blot (w/o ELISA!) Pretreat with the following supplements for 1 month: (Immune modulators) Grape Seed extract 200 mg bid Propolis Extract, 2 hs on an empty stomach every 3 days o Available on Amazon

28 Lyme Disease is a Clinical Diagnosis! The CDC advises: The surveillance case definition was developed for national reporting of Lyme disease; it is not intended to be used in clinical diagnosis. The FDA advises against an overreliance on serologic testing. If your level of suspicion is high, regardless of test results: REFER! Lyme disease--united States, MMWR Morb Mortal Wkly Rep. Jun ;56(23): Brown SL, Hansen SL, Langone JJ. Role of serology in the diagnosis of Lyme disease. Jama. Jul ;282(1):62-66.

29 Develop a referral network ILADS International Lyme and Associated Diseases Society Find Lyme Literate Providers (LLD s) in your area Connect/Interview Look for Mold Literacy! Look for individualized treatment What to expect Remission, not cure 85 to 90% of patients feel 85 to 100% better within 2 years

30 Is it appropriate to test and refer everyone who has a positive questionnaire? No! If the following are true: o Very minimal severe symptoms and none that are disabling o Psychiatric illness well controlled with current medical regimen o Quality of is life good o They are not within the first year of initial infection Discuss your level of suspicion and the choice to test with the patient

31 Benefits of knowing: Preparation, and avoidance of triggers. Supplements for immune, detox, and anti-inflammatory support Vitamin D, 5000 to 10,000 U/day Levels of 70 to 100 Omega 3 s 1600 to 2000 mg EPA 2000 to 2400 mg DHA Bio-available curcumin: 1 gram bid Things to avoid: Glyphosate EMF (Electromagnetic Frequencies) Moldy buildings Steroids Stress Another tick bite Elective surgery

32 Pilot Study Teen residential treatment center 10 residents with at least 3 years of MDD/GAD/ODD Tested for Tick Borne Disease 2 positive for Lyme (5 highly suggestive) 4 positive for Tick Borne Relapsing Fever (2 suggestive) Different Borrelia species, very common in the west, very similar illness 3 positive for Bartonella (1 suggestive) Overall: 6 definite positives for one or more tick borne infections 3 additional with indications of probable infection Only one teen with no evidence of possible tick borne infection!

33 Auto-immune encephalopathy as a cause for psychiatric disorders Examples: Anti-NMDR encephalopathy (Watch Brain on Fire ) PANDAS - Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections ANDAL - Autoimmune Neuropsychiatric Disorder Associated with Lyme Pilot Study Results Cunningham Panel 5 anti-neuronal antibodies 9 out of 10 teens positive for anti-neuronal antibodies! 6 out of 10 had three out of five positive antibodies! Sweto et al. (The American journal of psychiatry. 1998;155: ) Chandra et al. Anti-neural antibody reactivity in patients with a history of Lyme borreliosis and persistent symptoms. Brain Behav Imm. 2010; 24:

34 Psychiatric illness is multi-factorial CURRENT PARADIGM Major contributors to pathogenesis: 1. Trauma 2. Genetic predisposition Treatment: Therapy Psychotropic meds SHIFTING PARADIGM Also: 3. Chronic infectious disease 4. Autoimmune encephalopathies 5.??? Treatment: Treat the infections Support the immune system???

35 Invitation Brief experiment Two weeks Every patient with chronic and/or difficult to treat: o Anxiety o Depression o Bipolar o Irritability/rage/ODD What you will gain: 1. Familiarity with the questionnaire 2. Identify patients who could benefit from treatment 3. Expand our knowledge about true prevalence in psychiatric patients

36 First, the truth is ridiculed Then it meets outrage Then it is said to have been obvious all along Arthur Schopenauer ( )

37 Appendix

38 Acute vs Persistent Chronic Lyme Disease Acute o Tick attachment or bullseye rash o Flu-like illness o +/- antibiotic treatment o often misdiagnosed or absent Chronic o 80% do not remember a tick attachment o 85% have no hx of bullseye rash o Most have no awareness of acute infection Clinical Course o Relapsing/remitting o Slowly progressive o Rapidly progressive o Long latency followed by activation

39 Reasons for persistence Immune suppression Sequestration in antibiotic privileged sites Borrelia biofilms Atypical/cystic forms Long replication cycles Polymicrobial infections

40 Western Blot Results are counterintuitive and often misinterpreted Persistent IgM o Infections persist w/o adaptive immunity o Often considered false positive The sicker the patient: o The more their immune system is suppressed o The less likely they are to have a positive antibody test The not-as-sick patients: o More likely to have positive tests

41 Q + A