Friday, May 27, 2011

Contested illnesses and naturopathic medicine: Morgellons disease

Naturopathic doctors are no strangers to contested illnesses. Without making any statement to the validity or non-validity of said illnesses, such illnesses include multiple chemical sensitivity, chronic Lyme disease, chronic fatigue syndrome, candidiasis, and others. Naturopathic doctor’s status as alternative healthcare providers means that patients who are frustrated with traditional medical doctors often seek them out for treatment of these illnesses. Patients sometimes seek NDs out for help with contested illnesses because the treatments they have been prescribed are ineffective, but frequently they seek out NDs because they feel disrespected by their medical doctors, and that their sufferings are not taken seriously.

One such illness is Morgellons disease, a condition which has risen from obscurity to national prominence in the past decade. The term itself was resurrected from the annals of medicine, having originally been applied to a condition observed in 16th century rural France, a condition characterized by the emergence of coarse ‘hairs’ from the skin, convulsions, and upper respiratory symptoms. The term was then used sporadically through the medical literature until the end of the 19th century, during which time it was used to describe a variety of parasitic-like infections. By the end of the 1800s, it had more or less disappeared from use. Since 2002, the term has appeared in popular culture to describe a condition characterized by non-healing skin lesions with associated fibers being found in the lesions or the skin.

What makes the disease contested is the fact that the ‘medical establishment’, if one can cast such a broad net, questions the validity of Morgellons as a true disease. Most people who have Morgellons disease are self-diagnosed, having read about Morgellons on the internet. Very often, dermatologists diagnose these patients as having delusional parasitosis, a fixed belief in having an ‘infestation’ by some bacteria, parasite, etc., despite no objective medical proof.

Recently, The Mayo Clinic published a report on 108 self-diagnosed Morgellons sufferers, which concluded that 107 of the patients had no evidence of any infestation or infection, despite their firm conviction that they did. The 108th patient indeed had an infection, but one already described by science. The study included examination of materials brought to the clinic by patients (which the patients claimed as evidence of infestation), as well as biopsies of the characteristic lesions. The CDC is due to publish a report on their investigation of Morgellons later on this year, the content of which is not yet public, but which has been in progress for the last two years.

This research is much-needed, and will hopefully further our understanding of this phenomenon. Interestingly, despite the fact that a Google search for ‘Morgellons’ produces over 250,000 results, a search for peer-reviewed literature on PubMed produces only 30 results. Of those thirty results, the content is mixed; some are letters to editors of medical journals, many others are discussions of delusional parasitosis (which only briefly mention Morgellons as a patient-reported disease), and one of which is a study of the sociology of Morgellons. Clearly, the Internet has become a major source in both the diagnosis and treatment of Morgellons, a fact noted by physicians (1, 2).

I want to underline the fact that I am not making a statement here as to whether or not Morgellons exists as a discrete disease with a specific bacterial or other etiologic cause. As I hope the prior paragraph has indicated, there is very little information on which to make that judgment. The history of medicine is full of examples of originally laughable theories being proven correct – germ theory, the basis of much of modern medicine, was ridiculed when it was first suggested. That said, the history of medicine is also full of beliefs later disproven, such as miasma theory (which germ theory replaced). Indeed, there is reason to believe that the term Morgellons disappeared from the medical literature in the late 19th century because germ theory allowed for better, more accurate descriptions of the symptoms previously ascribed to Morgellons. I’m withholding judgment until the CDC article, which will be released in a few months.

Morgellons presents a real challenge for the traditional medical model and medical system. The patients themselves seek out dermatologists, who are often unable to find positive proof of an infection or infestation (though as has been pointed out, a complete and thorough examination is necessary to rule out an identifiable illness, and there are many diseases to be ruled out). Dermatologists thus diagnose delusional parasitosis, not only because of the absence of an identifiable pathogen, but also because of the disbelieving, sometimes confrontational attitude of Morgellons sufferers, a symptom acknowledged by the Morgellons Research Foundation and attributed to the effect of the as-yet-unidentified pathogen. Dermatologists then refer patients to psychiatrists for treatment of what they have diagnosed as a mental health condition, which is in turn resisted by Morgellons sufferers, who insist that they do have an actual, physical infestation that needs treatment. Psychiatric medications have proven effective for delusional parasitosis, but no research has been done on their use for Morgellons, though a few case studies have been published on their use in Morgellons (at least one was successful).

Part of the challenge Morgellons presents to medicine is due to specialization – Morgellons patients, convinced that they have a material infestation of some sort, seek out dermatologists. The scope of dermatology, however, is limited, and as no clear diagnosis of physical pathology can be made, they refer to psychiatrists. Morgellons patient, frustrated and feeling that their symptoms are not being taken seriously, often reject a psychiatric diagnosis and withdraw from the medical establishment altogether, seeking alternative treatments, many of which are propagated via the Internet. In an effort to prevent this, and keep patients in contact with physicians, guidelines have been written for patients and physicians on Morgellons disease that emphasize compassion, empathy, and the need for open minds for both parties (1, 2, 3). One such article suggested using the term Morgellons as a rapport-enhancing term for patients, though under the pretext that these patients had delusional parasitosis.

Naturopathic doctors, and all primary care providers for that matter, are in a position that allows them to knit together all of a patient’s symptoms, and not just refer to a mental health specialist. Because of our training in multiple areas of human health, we have the opportunity to form a strong therapeutic alliance with patients suffering from Morgellons, and not having to insist on referral. This gives us the opportunity to keep these patients under medical supervision as they seek treatment, rather than having them flee the medical profession to seek out potentially unsafe treatments on the internet, a major source of information on Morgellons.

Perhaps ironically, the exact cause of Morgellons doesn’t necessarily matter to a naturopath. Whether it is due to a bacterial infection or just a delusion, the core determinants of health remain of primary importance – nutrition, sleep, hydration, exercise, healthy relationships, etc. In complicated cases that may take some time to unravel, we are taught to work first and foremost on these factors, and then seen what remains to be dealt with. If Morgellons is indeed bacterial in origin, proper lifestyle may help the body’s immune system become strong enough to combat the bacteria itself, possibly without the assistance of antibiotics of some sort. If psychological in origin, the lifestyle changes will help establish healthy neurological function.

Finally, I would like to mention that I believe that medical systems with alternate forms of diagnosis, such as acupuncture or homeopathy, have a role to play here. Clearly, Morgellons is testing the limits of our system of diagnosis – whether it is a physical illness with mental symptoms or a mental illness with physical symptoms, standard Western pathological definitions and treatments often have difficulty bridging that gap. Acupuncture and homeopathy, with their holistic systems of diagnosis that do not view the body and mind as separate, may be useful in treating these patients. As the jury is still out on the cause of Morgellons, these two systems may offer a viable alternative because of their stronger emphasis on symptom picture, rather than etiologic factor. Additionally, these practitioners may have the ability to foster a greater therapeutic alliance, because they can honestly say that they are treating the patient as a whole, and that it doesn’t absolutely matter whether or not the cause is physical or mental.

People suffering from contested illnesses have always sought out alternative providers. As naturopathic doctors, we have a unique opportunity to work with these patients because our treatments are so fundamental, and most will not change no matter the exact cause of the illnesses. At the same time, it is important that we stay abreast of research, so that our understanding is fully up to date, as it will guide our treatment in more challenging cases that do not respond to less forceful methods. And as always, it is crucially important to recognize that Morgellons sufferers are just that – suffering. Regardless of the cause, their suffering must be acknowledged and taken seriously.

Friday, May 20, 2011

Tons of food, trillions of bacteria, limitless questions

It’s an oft-repeated phrase among scientists that we know more about the moon than we do our own oceans. The exact same thing could be said about the human digestive system – it’s right under our noses, and yet it’s one of the least-understood organ systems in the body. I mean, in a organism in which everything has a function and space is at a premium, the abdomen contains multiple semi-vestigal organs (the greater omentum, anybody?).

By contrast, most other organs are well understood in their major and minor functions. The kidneys, for example, are a system governed by hydrostatic and osmotic pressures, that then communicate that information to the rest of the body via hormones. Likewise, the heart is a mechanical pump, and not much else.

The gut, however, is a complex interplay of bacteria, enzymes, neurotransmitters, foods, membranes and immune cells. While the cardiovascular system evolved in an effort to move fluid and nutrients around the body, the digestive system was an attempt to tame the wilds of the ocean so that we could harvest nutrients from it. As a result, the digestive system is more like a controlled ecosystem than a mechanical apparatus. After all, there are more bacterial cells in the gut than there are human cells in the rest of the body.

While researchers have a reasonable handle on certain parts of the digestive process, such as enzymatic digestion and absorption, the interplay between food, bacteria, and the immune system is still one of the biggest mysteries in modern science. Research into these relationships will help to answer at lot of questions, such as:

  • What’s the benefit of probiotics? Is it just a question of outcompeting pathogenic bacteria? Why do some studies show benefit even from killed lactobacilli? Who should take what species of probiotics?
  • How do beneficial bacteria interact with the immune system? How do they signal to the immune system? What does the immune system do upon receipt of these signals?
  • How does bacterial digestion affect medications or herbs? Should some people take some over others?
  • What’s the deal with food intolerances? Is it the food itself, or something else that people react to? Does it happen in the bloodstream or in the digestive tract? How can get decent lab tests for food intolerances?
  • And finally, what the heck is IBS, really?

This is about as straightforward as trying to figure out how all of the birds, mammals, insects, bacteria, plants, fungi, viruses, weather patterns, pollution, human activity and magnetic forces in the entire Amazon basin affect one species of tree.

However, an article recently published in Nature has shed some light on one aspect of this question. It appears, based on a small study, that several distinct bacterial ecosystems exist in human digestive tracts. While this doesn’t yet offer explanations to many of the burning clinical questions we have, it represents a massive step forward in mapping the terrain of the digestive system. In the same way that discovering blood type in the early 1900s yielded vital clinical information that saved many lives, in addition to helping to push forward our understanding of the immune system, the discovery of enterotype is likely to yield clinical results and also help elucidate some of the subtleties of the immune system, and how it interacts with food and symbiotic bacteria.

Most surprising, I think, is that the bacterial populations were not organized around Lactobacillus, Bifidobacterium or other commonly-studied probiotics. Instead, they were organized around the species Bacteroides, Prevotella and Ruminococcus, names which to date have had little clinical significance. There is also some indication that these bacteria may, and I do mean may, direct the formation of an environment beneficial to certain bacterial strains. More information is likely to come out in the next few years as larger studies are performed – there is already an indication that enterotype 3, centered around Ruminococcus, may include multiple subtypes.

Stay tuned.

Friday, May 13, 2011

An intro to green tea

I’m a huge fan of green tea. I usually start my day with a few cups of a nice, strong brew, which to me are like a life-giving beverage. Not merely an eye-opener, green tea is a restorative that reinvigorates the body with its potent blend of antioxidants, vitamins, and minerals.

Though tea has been a much-beloved beverage the world over for thousands of years, in recent years, green tea in particular has been discovered to have immense health benefits. A PubMed search for ‘Camellia sinensis’, green tea’s Latin name, yields over 1,100 results, while a search for ‘tea’ yields over 16,000 results, making it one of the most heavily researched substances in the naturopathic toolkit. It’s been studied for a variety of conditions, ranging from cancer to weight loss to arthritis. A complete survey of green tea’s documented health effects is far beyond the scope of this blog, so let’s boil it down by saying, ‘Green tea is good for you.’

The majority of the health effects are due to four main constituents: vitamins and minerals, non-vitamin antioxidants, caffeine, and theanine. To help you on your way, here’s a brief explanation of each.

Vitamins and minerals – Green tea is a veritable multivitamin, as it contains carotenoids (some of which your body converts into vitamin A), ascorbic acid (vitamin C), and tocopherols (vitamin E). These all have antioxidant effects and add to green tea’s benefits. Additionally, a variety of minerals are found in tea depending on the soil in which the tea was grown. Selenium and zinc are some of the minerals found in tea, both of which have antioxidant function in the body.

Antioxidants – The antioxidants in tea can generally be categorized as polyphenols, but are sometimes subcategorized as catechins and gallocatechins. Research has show than these polyphenols are directly absorbed into the bloodstream, where they have a variety of actions, including their main function as antioxidants. As an example of their antioxidant activity, they have been shown to prevent oxidation of LDL (‘bad cholesterol’), thus preventing heart disease. In addition to this primary effect, these compounds are antibiotic, antiviral, immune-stimulatory, antimutagenic (they prevent DNA damage, thus preventing cancer), and improve detoxification by the liver. Could you really ask for anything more?

Caffeine – One of the reasons people avoid green tea is due to caffeine. One of the reasons other people embrace green tea is due to the caffeine. In my view, it’s just part of the tea experience, good or bad. Caffeine’s well-known effects include improved sense of alertness, well-being and energy. As a reference point, the caffeine content of a cup of green tea is about 25 mg, a cup of black tea contains 50-60 mg, whereas a cup of coffee contains 150 mg.

Theanine – A little-known amino acid, theanine is found abundantly in green or white tea, but is not present in black tea (it’s destroyed in the fermentation process). Sometimes described as the compound in green tea that generates the ‘zen’ effect, theanine works by increasing the amount of the calming neurotransmitter GABA. As a result, theanine helps to balance the stimulating effect of caffeine, generating that calm uplift for which green tea is known.

Finally, a brief primer on how to brew green or white tea. I brew almost exclusively loose-leaf tea, and rarely brew flavored tea. Tea is generally flavored to hide unpleasant tastes, either in the tea itself, or as a result of poor brewing – good brewing will allow you to explore the universe of teas in their exquisite natural splendor. Like wine, tea comes in endless varietals that range from the elegantly simple greens of Japan, to the flowery oolongs of Taiwan, the spicy chais of India, and the dignified, formal black English breakfast teas. A trip to your local teahouse will find you oohing and ahhing over the varieties available.

The run-down on brewing green tea:

1) Unlike your standard Lipton black breakfast tea, green tea should never be brewed in boiling water. Boil your water, then let it cool for a minute or two before pouring over tea leaves. Water that’s too hot will make your tea bitter – avoid it.

2) Don’t brew your tea too long. Three to four minutes is generally long enough (a few teas are brewed less), after which you should either fully decant your tea from the pot, or remove your brew basket from your mug of tea. Brewing for too long will also make your tea bitter.

3) Brew your tea a second time! Good quality leaves will be able to be brewed at least twice, some a third or even fourth time. For your second brew, increase the brewing time by a minute or so.

4) And a last tip – most green, white or oolong teas should leave a nutty, sweetish taste in the back of your throat. I’m not sure what the source of that sweet taste is, but it’s an indicator that you are brewing correctly.

And that’s it! There are, of course, more elaborate ways of brewing, including timers, digitally-controlled kettles, and elaborate tea pots, but anyone can make a dang good cup of tea with little more than a brew basket as special equipment.

Regular readers of this column will know the value I put on a simple but balanced diet combined with certain superfoods, such as tea. Not to mention the fact that tea connoisseurship will make you one of the more ~refined~ people you know. To your health!

Friday, May 6, 2011

A personal perspective on Death with Dignity laws

At 52, Cody Curtis was diagnosed with cholangiocarcinoma, a cancer affecting the bile ducts of the liver. Soon thereafter, she would undergo a surgical removal of the primary tumor, during which most of her liver was removed as well. Though the surgery was deemed successful, complications ensued, and she was hospitalized for some time afterwards. I remember visiting her while she was in the hospital soon after the surgery – she was clearly in pain and wasn’t fully coherent. I remember thinking how hard it must have been for her husband, Stan, and her children, Jill and Thomas, to have her there, but not really there.

After an extended stay in the hospital, things started looking up – she was in apparent remission, she was upbeat, and she was regaining her strength. I remember visiting a couple of times in that time period. Cody was weak and easily fatigued, as anyone recovering from cancer would be, but was making strides towards health.

This upward movement was not to last, however, as she suffered a recurrence of her liver cancer a year later, and additionally, it had metastasized to her lungs and lymph nodes. At that point, her doctors said that there was nothing more that they could do.

A resident of Portland, Oregon, Cody decided to take advantage of the ‘Death with Dignity’ law that has been on the books since 1994. Death from cholangiocarcinoma is not pretty. It’s slow, it’s painful and it’s degrading. Having already been through so much pain and suffering, and having seen the toll that it took on her family, she decided to ask her physician for a lethal prescription.

In 2008, Washington state passed Death with Dignity legislation. When it had first appeared, I was in favor of it. After all, it was only humane. My own mother had passed away after a protracted battle with ovarian cancer that became uglier as time went on, and I felt others should be allowed to decide to avoid that.

However, when I reached the voting booth, I faltered. I found myself thinking of loved ones and couldn’t decide what I would do when placed in that situation. Faced with a terminal diagnosis, could I ask my physician for a lethal prescription, or support someone doing the same? I abstained. I wouldn’t mark no, but I couldn’t mark the yes box. I left the voting booth with an empty space on my ballot.

Cody changed that, and I can now honestly say that I am fully in support of Death with Dignity laws. Most of us would probably want to go quietly in our sleep if we could, but that is not a luxury afforded to those with terminal illnesses. Adding to the already difficult process of getting affairs in order, preparing to leave family members, and coming to terms with mortality, there is an element of fear that pervades life. Fear of painful symptoms, fear of hospital visits, fear of the suffering your family will go through. Additionally, there is treatment. Remarkable as it is to say, though treatment for the dying can provide some comfort, it also prolongs the agony, and adds to the fears and stresses. I can speak to that myself; a dying person is in and out of hospitals in their final months, they have symptoms, they eat more medication than food, they have side effects and they have pain.

Additionally, there is the subject of coherence. Late stage diseases are often terribly painful, and are heavily treated with pain-killing medications. While a patient may not be in pain, their ability to think, speak, and interact is heavily impaired. A drawn out, terminal illness allows the time to have family and friends visit and say goodbye, but sometimes that comes at the price of knowing they are there.

Having the lethal prescription available freed Cody from the fear of what would be come of her and her family. Taking charge of how and when she would die allowed her to focus on the most important things in life. She spent time with her husband and children. She went walking in the park on those rare, but beautiful, sunny days in Portland. She cooked a delicious and lavish last Thanksgiving dinner (I was there – it was fantastic). She was free to truly savor her remaining time on earth and do so knowing that when her illness became overwhelming she didn’t have to put herself or her family through it. She knew that suffering wasn’t in her future. Somewhat ironically, she was filled with an optimism that many people in the prime of life don’t have.

She passed away peacefully in December of 2009, surrounded by her family. It had not been an easy path to tread, but I know her husband and children wouldn’t have had it any other way. In a culture where death is feared and hidden, Cody both lived and died with a grace and dignity that should serve as an example. Her story is both somber and inspirational, and I consider it an honor to have known her.

This year, the Grand Jury Prize for a Documentary film at the prestigious Sundance Film Festival went to the film How to Die in Oregon, which follows Cody through those final months of her life. It is currently being shown at film festivals around the country, and will be premiering on HBO at the end of the month. I have not had the opportunity to view the film, but the reviews say that it is a beautiful, though challenging, film. I urge you all to mark your calendars and tune in.