The Dr. Hyman Show - Treating OCD From A Functional Medicine Perspective with Dr. George Papanicolaou

Episode Date: September 27, 2021

Treating OCD From A Functional Medicine Perspective | This episode is brought to you by Rupa Health and Athletic Greens Obsessive Compulsive Disorder, or OCD, affects approximately 2.2 million adults and 500,000 children in the US. Individuals with OCD often experience impulsive and intrusive thoughts that replay in the mind, in addition to behaviors such as excessive cleaning and repetitive counting. While conventional medicine approaches OCD as a chemical issue, Functional Medicine looks at genetic components, inflammation, gut health, and other lifestyle influences in its treatment of OCD.  In this episode, Dr. Hyman discusses OCD with Dr. George Papanicolaou. They discuss just how debilitating this condition can be and share case studies of how they have treated patients with this condition. George Papanicolaou is a graduate of the Philadelphia College of Osteopathic Medicine and is Board Certified in Family Medicine from Abington Memorial Hospital. He is also an Institute for Functional Medicine Practitioner. Upon graduation from his residency he joined the Indian Health Service. He worked on the Navajo reservation for 4 years at the Chinle Comprehensive Medical Facility where he served as the Outpatient Department Coordinator. In 2000, he founded Cornerstone Family Practice in Rowley, MA. He practiced with a philosophy centered on personal relationships and treating the whole person, not just not the disease. He called that philosophy “Whole Life Wellness”. Over time as the healthcare system made it harder for patients to receive this kind of personal care Dr. Papanicolaou decided a change was needed. He began training in Functional Medicine through the Institute of Functional Medicine. In 2015, he established Cornerstone Personal Health—a practice dedicated entirely to Functional Medicine. Dr. Papanicolaou joined The UltraWellness Center in 2017. This episode is brought to you by Rupa Health and Athletic Greens. Rupa Health is a place for Functional Medicine practitioners to access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, Great Plains, and more. You can check out a free live demo with a Q&A or create an account at RupaHealth.com.  Athletic Greens is offering Doctor’s Farmacy listeners a full year supply of their Vitamin D3/K2 Liquid Formula free with your first purchase, plus 5 free travel packs. Just go to athleticgreens.com/hyman to take advantage of this great offer. In this conversation, Dr. Hyman and Dr. Papanicolaou discuss: What is OCD and who does it affect? Common behaviors of someone with OCD Conventional diagnosis and treatment of OCD The genetic component to OCD How the gut microbiome and lack of diversity may contribute to OCD Identifying inflammation as a root cause   A case study of someone who has OCD Functional Medicine approach to treatment of OCD Additional Resources: How Eliminating Gluten May Improve Anxiety and Depression Understanding How the Microbiome Affects Every Aspect of Your Health The Science of Mood and Your Microbiome How Leaky Gut is Making Us Sick and Driving Chronic Inflammation with Dr. Emeran Mayer

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Welcome to The Doctor's Pharmacy. I'm Dr. Mark Hyman and that's Pharmacy with an F. A place for conversations that matter and if you or anyone you loved or know has struggled with OCD or obsessive compulsive disorder, you better listen up because we're having a great conversation about what to do about it. The answers might surprise you. For sure, it's not the typical take the drugs and cross your fingers and hope for the best and they don't really work anyway, which is the typical approach. And today we have the privilege of having none other than Dr. George Papanikolaou, who's one of our key physicians at the Ultra Wellness Center in Lenox, Massachusetts. He's a graduate of Philadelphia College of Osteopathic Medicine. He's board certified in pain medicine. He's certified in functional medicine. He's done

all kinds of cool stuff like work on Native American reservations and founded his own practice and has come to work with us a number of years ago. And he's just an awesome dude. So welcome, George. Mark, it's always a pleasure. Thanks for having me today. Okay. So OCD is a problem and it affects people and it really ruins their life. It takes over their minds in ways that control their thoughts, their behaviors, their actions, and their lives. And it's a really vexing problem for a lot of people. And it's also one that is hard to treat with traditional medicine. So tell us about how common is this? What are the symptoms? What do we know about it? What's the general sort of approach?

And then let's get into sort of a functional medicine perspective. So OCD, it's obsessive compulsive disorder. So as Mark, as you said, it is very uncomfortable for people because they have intrusive thoughts that they don't want. They have thoughts and images, impulses that occur over and over, and it's out of their control. And that's that obsessive thing. One person described it as being on the side of a raging river, falling in and not being able to get out for hours. And not having any control while you're in that river. So then you have the compulsions. So that's the second part.

The compulsions are those behaviors that a person engages in to try to neutralize or counteract those obsessions and the feelings of anxiety and anger and agitation and frustration that they have. Because when this happens, when they have those images, when they have those compulsions, it keeps them from being able to be productive in relationships and at work. And it's very difficult to conduct a life. That's obsessive compulsive disorder. That's what it will look like. It affects about 2.2 million adults, 500,000 children, which is about 1% of our population. The average onset of OCD is 19 years old. And 25% of people with OCD experience it before the age

of 14. So that's about one in 200 children will have it. And so in an average size elementary school, two to four kids will have OCD. And in a large high school, about 20 kids will have OCD. It's rough. Yeah. And the compulsions, like what are the most common compulsions that people have that we know about? Yeah. So common compulsions are going to be repetitive behaviors, repetitive thoughts. They'll be thinking like excessive cleaning, washing, bathing. They're afraid of contamination. They're afraid of dirt. They're afraid of chemicals. They're afraid of those types of things. And they're afraid that they're going to cause a disaster, like something they do

if they drop a piece of paper or if they leave something in the driveway. They're afraid that they're going to cause a car accident or somebody's going to slip and fall. It's going to be their fault. Now, we all have those thoughts, but these just occur and occur and occur over and over and over again, and they can't get it out of their mind. So that will lead into checking, and they'll go in and out of doors because the door didn't close right. They'll do repeating things. They'll count. I had one patient who would, when their movie credits were rolling, she would focus in on the letter Z and count how many times it would show up in movie credits.

Wow. Yeah, no, it's pretty bad. I mean, I've had a number of patients that are just really horrible. It's controlling. One woman just in particular was so striking. She never cleaned her house because she didn't want to move anything off the floor. And she had some compulsion or obsession about it, being able to not deal with that. And her house was a scary place.

And, you know, she'd think she was a crazy person. We talked to her. She seems reasonable and nice. But you go into her home and it's like a nightmare. And, you know, it was really unexpected what we found worked for her because she tried lots of things and nothing worked. So let's talk a little bit about the approach you would take from a functional medicine perspective.

How do we think about this differently? What are the kinds of things we want to look at? Because it is something that really affects people's quality of life um right they have trouble with social engagement they they really struggle to kids who have it struggle to leave home and live by themselves it's hard to have relationships and you know these kids often remain financially dependent and so they like from a traditional medicine perspective we don't really have a kind of a clue about why this is happening, right? But what do we know about the causes? Well, so I want to remind, and you've said it already, it starts when you're young, it peaks around 19,

and it continues chronically through life. It doesn't go away. And I want that, it's an important point to make, because when we talk about the treatments that are the conventional treatments, I'm going to make some points about their effectiveness. And it's important that they be effective long term. Yeah. You know, just as an aside to this, because I think it's important to understand as we start talking about the differences is that the, and we might as well just jump right in,

that the common understanding of OCD is that it's, there are many potential causes, by the way, but in conventional medicine, it's more seen as a chemical issue and it's treated with serotonin reuptake inhibitors because it's considered the primary issue is low serotonin. Now, there are multiple other possibilities that I want to mention. But in conventional medicine, it's really practically treated as a simply chemical problem that has behavioral characteristics. So we use another technique that's been proven. It's the only intervention that's a counseling type therapy that's been proven effective, and that's cognitive behavioral therapy. So those are the two main therapies that you're going to be offered when you walk into a conventional doctor's office. And we know that there are other causes that, you know,

they're being studied. And these are one of the genetically, so there are some genetic factors. So some recent research that was done through John Hopkins and other networks of schools that got together, and they did a study using throughput genetic analysis where they're able to look at multiple series of genes so they can look at multiple genomes at once and they can really hone in on genes that are producing abnormal proteins and they can determine which ones are related to OCD. And just, it was, I think, just published this June in JAMA Psychiatry. And they looked at about 1,300 patients with OCD and age, you know, and then similarly matched controls. And they looked at the DNA in both groups and they identified a gene. It's called the SKRT, no, it's SLITKR5 gene. And it has been looked at before for OCD, but they found that it was very prominent in all of the people with OCD and not in the people without OCD. So they're really excited about this gene because then they can do this targeted therapy to be able to turn that gene off.

So there's genetics. There's an area that I think is really important. And, and I, there's more and more research being done is the idea of inflammation in the brain and the role of the, the role of the gut microbiome. And so as you know, you know, studies go back to 2017 when they did a research study at McMaster's University and they looked at 20 OCD patients and they again with match controls and they did DNA analysis of their stools and they found that people with OCD had a very low abundance and variety of the key bacteria in the microbiome versus their control group. So that was one study that started to have people start to think, well, the gut microbiome, we know in functional medicine, we know the strong connection between the gut and the brain.

And now there's more and more research trying to connect the gut to mental health and psychiatric disorders, particularly OCD. And other studies are being done, and one focused in more on trying to find species of bacteria that might be involved in OCD, whether they're inflammatory or whether they send other signaling to the brain, we don't know yet. But people who have OCD tend to be really low in lactobacillus remnosus and lactobacillus casei. And there's another bifidobacteria species. And so now research is getting us to the point where we're even starting to be able to investigate species of bacteria in the gut that play a role in OCD. We're not sure what that role is, but there seems to be a connection.

And they did another really cool study that looked at inflammation and dysbiosis. And this was in 2020, actually, at McMaster's University. And they used PET scanning to look at different areas of the brain. And they looked at blood, and they looked at stool. And what they were able to find was that people with OCD, again, building that previous study, had really low colonies, abundance of particular colonies in their gut, and they had limited diversity. So again, no abundance, no diversity. And so with those same people, they had a matched group, and the other group had a lot of diversity, a lot of abundance, and they also then compared inflammatory markers. CRP is an inflammatory marker.

IL-6 is an inflammatory marker. And PNF-alpha. And they looked at those inflammatory markers, and the OCD patients with that low abundance and low variety had high inflammatory markers as well versus the control group. So there's this building data and research. It's early yet, but starting to connect the gut microbiome to inflammation in the brain. And that's a really important thing. And so inflammation is, I think, one of the areas

that holds a lot of promise. Understanding the connection between the gut and the brain is really important. So the genetic piece, there is a biochemical piece. There are blood flow issues that have been identified. And so those are some of the important possibilities for what might be at the root cause. It may not be one thing. It may be all of those above, but it certainly isn't one thing. And that's how it gets treated in primary care. It gets treated as one thing, low serotonin. And we know that they're only about 50% effective and they have lots of bad side effects. Exactly. And those are the antidepressants like Paxil and other things they'll use for OCD. You know, you brought up a couple of things that

sort of reminded me of a patient I had, and this was really at the beginning. I wrote a book called The Ultramind Solution in 2008, I think. And in that, you know, in that book, I talked about these stories of patients who had remarkable, surprising findings. And, you know, I didn't really figure this out by doing the research, but by treating patients and see what happened in observing. And then I began to sort of dig into the research. And now the research sort of is picking up a little bit of what the clinical observations were, which was in this patient I told you who had really bad OCD. She could never clean her house. It was stuff on the floor all over. It was just like a disaster mess. Turned out when I did her testing, she had massive amounts of bacterial and fungal

overgrowth in her gut. And on your urine test, she had one of the highest levels I've seen of something called DHPPA, which is a clostridial metabolite, some particular bacteria. And it's known to have psychoactive effects. And it can be present in autism and other cases. And so I treated her with an antibiotic to get rid of that particular bacteria and also any fungal. And after like 15 years of never being able to like touch anything in her house and clean up, she was able to clean up her whole house, which was amazing to me.

Like you can give someone an antibiotic and any fungal and their psychiatric problems would go away because you're changing the messaging from their gut flora. Pretty remarkable. I don't know, Mark. It sounds like you may have just changed your obsession. Yeah. Your compulsion.

Yeah, it's amazing. Yeah, you changed your compulsion. Now she's a clean freak. But no, that's amazing. You know, one of the things that you just said, and I think that's when we talk about how functional medicine is different, and you've just been doing this for so long, for 20 years, is that it's observation. Observation and curiosity and digging deep and then say, hey, you know what? Look what I found.

And now, 20 years later, people are starting to look at the government. Now we're applying research. Now we're getting data. But that all started with people making observations and then, you know, and then talking about the results. And in your case, publishing your results in the books that you write. I think that's what we do in functional medicine. And that's awesome. That's a great case. Exactly. And, you know, it reminds me of some other causes you wouldn't expect, because we think this is a psychiatric problem, but it may not be really. It may be, you know, like some people get arthritis.

Some people get OCD. And one of the things you mentioned was an infectious cause, which is strep and PANDAS. Yes. And PANDAS is a pediatric autoimmune sort of neurologic condition that is related to strep. And the strep toxins, even if you get it when you're a kid, it may continue your whole life, you don't even know. And I'll just share a quick story. I want to hear sort of a little bit about what your thoughts about functional medicine approach and how we dig in. But this kid had an interesting story of OCD. And we did a particular test called PANDAS screen, which looks at the antibodies

against certain neurological markers. Yes, the Cunningham panel, which is something, by the way, you wouldn't get at your regular doctor. And he had a positive Cunningham panel, meaning he did have the PANDAS syndrome. And, and you know he'd been on antibiotics but doesn't seem to really work that well so i treated him with intravenous ozone recommended to go get ozone and he went and did that and completely went from like almost non-functional kid to totally normal. And I was like, holy cow. It's that simple. If we do things that kills the infections and the inflammation,

it's actually the thing that works rather than taking an antidepressant. Yeah, yeah. And ozone, it's antibacterial, antiviral. It has antioxidant capacity. It levels out your inflammatory response. So if there's an inflammatory response with the pandas, now known as pans, because there are other things besides strep that can cause it. Bartonella can cause it. Lyme can cause it. There are other viruses that haven't been identified yet.

And so it's an autoimmune process. That's why it can last. That's why you can get it, you know, have strep once and then have constant recurrences because now you've triggered your immune system and you're making antibodies against self-tissue. So yeah, very fascinating case. It's really powerful. And tell us about your case. You had a 14-year-old kid who had bad OCD and tics, because tics often go along with it, right? Yep. Yep. So, yeah, and I'll talk about some of the things we think about differently as I do the case, so that would be good. So the 14-year-old kid, it was actually a gal. She had OCD and a tic. Her parents divorced. It was a fairly ugly divorce. When she was five, prior to the divorce, it was just a chaotic household. And so she had, you know, a fair amount of trauma as a youngster.

And when she came to see me, she was, you know, now, you know, in high school, she was starting to struggle socially. And her, you know, she had this tick and she had obsessive thoughts about bad things happening, you know, about car accidents. And always fearful about being in a car, driving on highways, driving over bridges, and made it very difficult for her to have a social life. She came in. And of course, as part of the workup, we do stool analysis, we do nutritional analysis. I look for toxins like heavy metals, chemical toxins that could cause a disruption of the gut microbiome like glyphosate. We can measure that. Then we look for stealth infections. And there are markers that we can use to determine if somebody has, you know, been infected with strep,

even though they might not have current symptoms. So I do stealth infection workup looking for Lyme, Bartonella, strep. And then I assess gut permeability. So it can be not, strep, and then I assess gut permeability. So it can be not just strep, but it can be all these other things like tick infections. Oh, yeah, absolutely, yeah. And then I look at inflammatory markers, the ones I mentioned earlier, IL-6, TNF-alpha, CRP.

And then we also do, we look for single nucleotide polymorphisms or genetic workup. So for genes that have variations, so that when they make their proteins or enzymes, those proteins or enzymes, which, you know, and we can look at ones that are specifically involved in the neural networks in the brain and neurotransmitter metabolism and activation. We can look at those genes and we can find it. If that variation is making that gene work too slow, work too fast, maybe not even work at all. And if we can find those, they might be having an impact as well. So those are the tests that I did.

And what I found with her was that she did have dysbiosis or that imbalance of good and bad bacteria in her gut. She did not have a lot of abundance and she did not have a lot of diversity. She was kind of messed up down in her gut. Yeah, the gut was messed up. And I did a gut permeability test. And that test is looking at that very important permeable membrane filter that is the gateway to your immune system through the gut. And it has these gates that open and close in a very precise manner to allow all the good nutrients and compounds that bacterias make for us into our system. And at the same time, able to keep out the bad guys, viruses, bacteria, and toxins and so if those gates have been disrupted by a microbiome that has too many

unfavorable bacteria or if you have food sensitivities gluten egg dairy those things can break down the mucosa break down down that membrane, and now those gates are wide open, and you can have bacteria and viruses and toxins freely flowing through, and that creates systemic inflammation, and that's how the brain gets inflamed. You can also trigger autoimmunity, and now you can start making antibodies against self-antigen, and that can include the brain. So dysbiosis, leaky gut, did a nutritional analysis, and she was low in B6 and zinc. And we know B6 and zinc are really important for brain function, particularly in neurotransmitters. And so the last thing I found is in that genetic analysis, she had a blueprint for an enzyme that breaks down dopamine and

norepinephrine in the brain. And that enzyme worked really, really slow. So she had a buildup of dopamine and norepinephrine at baseline. So that type of genetic, the phenotype of that, what it looks like for a person when they have that gene variance is that they'll have less stress resilience because they have so much norepinephrine in the frontal lobe at baseline that any type of stress pops them right into fight or flight right away. And they get anxious and they can get panicky and agitated, irritated very quickly. If you combine that with the OCD, it makes it very difficult. So those are the things I addressed. So the gut gets inflamed and that inflames the brain and that causes all the crazy behavior. So we often think these are psychological problems, but they're not, they're biological problems. So now everything you just said, person has OCD and They're biological problems. So now, everything you just said,

person has OCD, and they're getting anxious. So what happens when you get anxious? You are in constant fight or flight, and now you have cortisol. You have the hypothalamus pituitary adrenal axis. That gets triggered. Cortisol rises inflate or inflate. And cortisol, we're finding through data and research, disrupts the gut microbiome, can cause shifts that are not favorable in the microbiome. And it also can trigger those gates, a breakdown in those gates so that it can trigger leaky gut. So now you have this terrible cycle. Bad gut, bad brain.

Now you're anxious. Now you have bad gut, bad brain, and it just goes around in a terrible cycle. So I treated her with probiotics. I gave her a probiotic that had lactobacillus, rhamnosus, and KCI, and then multiple groups of bifidobacteria species. For her leaky gut, I use, you know, glutamine and albuterate. Albuterate, I, you know, there are different things that you can use to heal leaky gut. I use albuterate because there's two reasons. One is, is that albuterate is a huge source of energy for the cells of the colon and it helps heal those those um those really

those tight junctions in those gates so it's really good for healing the colon it also in the brain modulates inflammation by regulating bleal cells so it it has a twofold purpose. So I chose, in her case, I chose to try to treat her gut with the butyrate and the glutamine and increased her foods that had B6 and zinc. I treated her genetic variants that predisposed her to poor stress resilience. I used some targeted supplements to allow her brain to account for that slow-acting gene. And having done all those things, you know, she also did some cognitive behavioral therapy. And she had a complete turnaround by the middle of her, by the middle of her year.

Um, she was feeling really comfortable. She could get in cars, she could drive, she'd go out to the movie theaters with her friends. Um, and it was, it was really remarkable. Amazing. Amazing. And I think, you know, that speaks to the fact that we really have not addressed psychiatric problems effectively in this country. Whether it's depression, anxiety, OCD, bipolar, and other brain issues like autism or ADD, we really have a very backwards approach that's based on old ideas about mental health and are all psychologically focused. And I'm not saying that psychological issues aren't real. They are, and trauma's real, and we have to deal with that. And there's a lot of wonderful approaches to that, including the new approaches

using medically assisted psychedelic therapy, which is called MAPS. And I think we're looking at other kinds of innovations. But for kinds of problems that just seem bizarre, like the OCD or even schizophrenia, you know, is not exactly a psychiatric condition. It's really biological, autism. And you can start to really change people's brain function by fixing their brain, by fixing their gut, by looking for tics, by looking for strep, by looking for imbalances in the floor, by heavy metals. All kinds of stuff will cause this. And I think the difference in functional medicines, we dig down into looking at your gut, looking at nutritional status, looking at toxins, looking at hidden infections, looking at inflammation markers and all sorts of things and genetics. And then we customize and personalize the approach to really help these people kind

of recover. And it's pretty amazing. So what happened to her? Well, as I said, she did really well. She, you know, continued to make it through her year. She did great. You know, she was still struggling a little bit. And so near the middle, three quarters of the way through school, you know, I think

in general, kids at that point, I talked about it with her mom, start to get school fatigue anyhow. And I think she was wearing down. So I did give her something called 5-HTP, which is a precursor to serotonin. And I gave it to her in a fairly higher dose than most people would use it to go to sleep at night because it can be used for that.

And that calmed everything down when she started to struggle near the end of the year we put her in 5-htp and she made a complete turnaround so uh she did great um she's going back to school i think yeah she's going back to school. I think, yeah, she's going back to school this year and I haven't heard yet how she's doing at this point. Amazing, yeah. Well, I think people are going to have lasting change and I think people aren't starting to feel like they're stuck in these horrible mental conditions.

And it's worth digging in. Even though it's a little bit dated, I think the Ultramind solution is really a great map of how to address the brain. And there are going to you updated protocols and stuff. But essentially, the framework is the same. And Mark, it's absolutely the same. Because every time I get on here to talk about a neurologic issue, I pick it up.

Is it good? Is it good? I'm looking at you. That was that was like a download from God. I literally sat in my office, in my house, and I sat for three weeks at 12 hours a day, and I just unloaded everything in my brain that was there after doing this for so many years and all the patience and the stories.

Mark, that was visionary work. You know, I don't know. I'm just paying attention to what's in front of me and just doing the best. So anyway, this has been a great conversation jordan i hope you've been listening and you have any struggles with ocd or other mental health issues that this has been heartening and that you've understood that there is maybe a path forward and i would encourage you to explore with a functional medicine doctor you can find one on the ipad website you can come see us for a little bit backlogged but we'd love to see you at the ultra wellness center we have five physicians

we have five nutritionists. We've been doing this for 20 years, probably more experience than any other practice. And it's in the beautiful Lenox, Massachusetts. So it's pretty nice to go to. And if you all have listened to this and you know someone who's struggled with these issues, rather than sort of just keeping this to yourself, share this podcast with them, let them know there's hope and a way of thinking about this differently. Subscribe wherever you get your podcasts. Leave a comment, have you overcome your health issues and mental health issues? We'd love to hear from you. And we'll see you next week on The Doctor's Pharmacy. Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy.

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