I saved this article as the last one in my autoimmune series because it’s arguably the most important. Autoimmune disease and mind-body medicine are tightly linked. 

Early on in my career I met a patient with mast cell activation disorder and chronic hives. She was so ill that she had been hospitalized a few times with her throat swelling shut. We worked on all sorts of things looking at environmental triggers, using supplements to reduce histamine, changed her diet - you know, the typical naturopathic treatments. She was a little better but nothing dramatic. I lost her to follow-up and out of the blue about 6 months later she sent me a message letting me know she had found a wonderful therapist who had changed her life. Her therapist recognized that my patient had an elevated ACE (Adverse Childhood Experience) score and they had worked extensively on her childhood trauma. Much to my patients' surprise, her very difficult-to-treat condition resolved. This was a turning point for me. I started researching psychoneuroimmunology and reading everything I could about the connection between our mind and our immune system. 

I am going to take a brief pause here to address what mind-body medicine IS NOT before I go on to explain all of the fascinating research. I want to be crystal clear that mind-body medicine is not about blaming the patient. I was surprised to receive an unpleasant message over social media after sharing some research on mindset and health about how unhelpful it is to point out this connection. I was surprised because I think it is incredibly empowering to know that we may be able to use our minds to heal our bodies. In my experience no one is free from the mind-body connection. We are all impacted by our minds. Once we are aware of just how powerful the connection is we are back in the driver's seat. So remember that as you continue reading. If your physical illness is manifesting in part due to emotional wounds, trauma, early childhood experiences, your mindset, etc. this does not mean that your illness is your fault AND there might even be some tools to help you. 

According to the Center for Mind-Body Medicine “Mind-body approaches use the conscious mind to directly affect the workings of the brain and the rest of the body. The techniques exert their effect on the hypothalamus, the switching station in the brain, which exercises control over the autonomic nervous system (which controls heart rate, blood pressure etc.), the endocrine (glandular) system and the immune system.”

The Autonomic Nervous System (ANS) is the part of the nervous system responsible for control of the bodily functions not consciously directed, such as breathing, the heartbeat, and digestive processes. It controls what is going on behind the scenes. You don’t have to think about digesting your food or sending out immune cells to fight off foreign invaders. The ANS has you covered. The ANS has two divisions, the parasympathetic and the sympathetic systems. These two systems oppose each other and ask for different responses from the organs and systems they control. For example the sympathetic nervous system will slow down digestive function while the parasympathetic system will increase digestive function. 

When the sympathetic (fight, flight, or freeze) is dominant we feel more tense and alert. Stress hormones such as cortisol and epinephrine surge through our bodies. Our heart rate and blood pressure increase. Our immune cells secrete inflammatory cytokines such as IL-6 and IL-2. In contrast, when the parasympathetic (rest and digest) system is dominant we feel a sense of relaxation, tranquility and contentment. This is the baseline of balance that our body desires. Our heart rate slows, blood pressure lowers, our muscles relax and we can digest food adequately. Unfortunately, many of us are sympathetic dominant in our daily lives.

There are so many mind-body medicine topics we could cover but I am only going to pick a few since this is a blog not a book. Let’s cover self-criticism, perfectionism and loneliness. While also incredibly important, I am going to leave ACE and trauma to the experts (see the bottom for some good books to read though). 

SELF-CRITICISM
When we are critical of ourselves, it has negative consequences for our health and even impacts our immune system. According to Merriam-Webster self-criticism is "the act of or capacity for criticizing one’s own faults or shortcomings." We have a complex system designed to monitor our environment for threats. When a threat is identified, we are flooded with stress hormones to help us survive. The trouble is, this system can’t differentiate between threats in our environment and threats inside our head. Criticizing ourselves activates our threat system in the same way anxiety does. Chronic stress happens when this system is constantly engaged. 

Chronic stress increases interleukin-6 (IL-6). IL-6 plays an important role in signaling during an active infection. IL-6 increases inflammation and antibody production. Elevated IL-6 actually increases anxiety, alters the immune system, and increases neuro-inflammation. 

We live in a culture that teaches us to be self-critical. We grow up internalizing the ideal that we must push ourselves to achieve greatness. It’s easy to put high expectations on ourselves, which leads to self-criticism when we can’t meet those expectations. Some use self-criticism as a tool to push themselves harder and harder and even fear that without the inner critic they might become "lazy."

A good rule of thumb is to stop and think about whether you would talk to someone you love the way you are talking to yourself. Most people would never speak to another person the way they speak to themselves.

PERFECTIONISM
Perfectionists are often the harshest self critics. Brené Brown, Ph.D defines perfectionism as “a self-destructive and addictive belief system that fuels this primary thought: If I look perfect and do everything perfectly, I can avoid or minimize the painful feelings of blame, judgement, and shame.” 

Self-criticism is used as a way to ensure you are "perfect." The lie perfectionists tell themselves is that constant second guessing means you will not make a mistake. The trouble is you spend so much of your life second-guessing yourself that you don’t get a chance to live in the moment. Instead, you are caught in a constant fight-flight-or-freeze sympathetic loop. 

I noticed a pattern in my practice that patients with autoimmune disease tend to be hard on themselves. I started looking into the research and I found this paper revealing that patients with autoimmune disease are more self-deprecating than controls, which confirmed my suspicions. Years of overwork and stress to prove your worthiness leads to chronic activation of your sympathetic system. Your stress activation system is closely linked with your immune system. The full mechanisms of action for self-criticism and immune activation are not fully worked out yet, but there is a connection. 

Just like Dr. Brown said, perfectionism is a misguided tool to reduce or minimize the painful feelings of blame, judgement and shame. Criticizing yourself and striving for perfection unfortunately do not produce the desired outcome and can harm your health. 

Instead, try holding a hand over your heart and saying to yourself: "I am enough."

LONELINESS
Another aspect to consider is loneliness. Loneliness actually changes how the immune system works. Cellular immunity is impaired, natural killer cells decline, and antibody titers rise. Loneliness triggers the fight/flight/freeze stress response. Humans have spent most of our existence as a species being supported and protected by each other. Loneliness signals to our body that we are in danger, which kicks up levels of inflammation and changes immune response. 

The real kicker for me is that folks who have or develop a chronic illness, such as an autoimmune disease, have a higher risk for becoming socially isolated. So not only does loneliness increase the risk of developing an autoimmune disease, having an autoimmune disease increases your risk of becoming lonely. 


We have so many mind-body medicine techniques at our disposal. Here are some resources I share with patients: 

• Tara Brach has free downloadable talks and meditations on her website and is also available on your podcast app.
• Sharon Salzberg offers meditations for download at no cost on her website. 
• John Makransky teaches a beautiful meditation style based on receiving love downloadable for free from his website.
• The Last Best Cure: My Quest to Awaken the Healing Parts of My Brain and Get Back My Body, My Joy, and My Life by Donna Jackson Nakazawa 
• The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel van der Kolk

In all honesty it doesn’t matter what tools you pick as long as you actually do it. Don’t wait until it’s convenient, you have to incorporate relaxing activities into your daily routine. I find myself falling into the same trap I hear from patients - I can manage the tools on days that aren’t too busy but sometimes (read most of the time) I am ‘too busy’ to get in that exercise/meditation/coloring, etc. These are the days that you need it most. Creating new habits takes time and I hope that learning just how important stress management is for your health will help inspire you to take the time to cultivate new habits to build resilience. 


If you are struggling with an autoimmune disease I recommend working with a naturopathic doctor to help identify the root cause and support your body. It is important to maintain all medications while working on your health from a holistic perspective. Autoimmune disease is serious and tissue destruction is permanent. Our goal with naturopathic treatment is to keep the medication dose stable and slow or stop the autoimmune destruction. I am often asked if patients can expect to stop their medication eventually and that depends on a variety of factors and is a decision made with the prescribing practitioner and patient. 
 

References:
Self compassion as a predictor of interleukin-6 response to psychosocial stress
Compassion meditation reduced stress induced immune changes
Neural concomitants of immunity--focus on the vagus nerve
Personality traits and the immune system
IL-6 Induced by Social Stress
What is Mind Body Medicine

Autoimmune disease occurs when our immune system starts attacking our own tissues. Autoimmune diseases are complex illnesses that develop when there is just the right combination of genetics, epigenetic factors, and environmental triggers (infections, chemicals, stressors, etc). In this article I will focus on a few chemical or xenobiotic exposures that are linked to the development of autoimmune disease.  I want to start by saying it’s very challenging to conduct research trying to link specific chemicals to any disease. Humans are exposed to a myriad of chemicals daily and there is likely a compounding effect happening. There can also be a long delay between exposure and the onset of disease. For example, someone could work in a hair salon touching and inhaling chemicals for 10 years before they finally develop an autoimmune disease. Drug (ie medication) induced autoimmunity is well known and most associated with SLE (lupus) like disease. I will skip that in this article. I want to focus on chemicals in our environment that we can control. 

Endocrine Disruptors
Arguably the most notorious endocrine disruptors we are exposed to are bisphenols with BPA being the most well known. Unfortunately, when the dangers of BPA were brought into public awareness we saw a boom in ‘BPA free’ products that are quite misleading. Many of these products just replaced BPA with it’s cousins BPF and BPS which are also estrogen like compounds. Bisphenols are used in the production of polycarbonate plastics and at this point are ubiquitous in our environment. Research from 2003 found that more than 90% of the US population has detectable levels of BPA in their urine and females BPA levels were at higher concentration than males. Growing concern about the impact on children from bisphenol exposure has caused BPA to be banned in baby products in Canada and the European Union. BPA is a known endocrine disruptor but it’s role in autoimmunity has not been elucidated yet. What happens to our bodies from BPA exposure is quite similar to the autoimmune process. More research is needed but I am concerned that this could be a potential trigger and the people who already have an autoimmune disease may see a worsening in their pathology with higher exposure to bisphenols. 
Some of the products where bisphenols are found include:

• Food packaged in cans or tetra packs
• Beverage cans
• Hard translucent plastic marked #3, 6 or #7
• Cash register receipts
• Plastic food wrap
• Frozen meals in plastic trays
• Heating or microwaving plastic
• Placing plastic in the dishwasher

One relatively easy change is to avoid plastic containers for food or water and opt instead for glass or stainless steel. 

Phthalates are another endocrine and immune disruptor that are ubiquitous in our environment. Phthalates help make plastic soft and to dissolve raw materials when making fragrances. In the US, chemicals such as phthalates are considered safe until they are proven dangerous. Unfortunately, most of the research on phthalates has been done on animals. A 2019 study in rats found that a particular phthalate exacerbates the most common autoimmune disease, an autoimmune thyroiditis called Hashimoto’s. 

Below is an example of products that may contain phthalates. 

• Plastics both PVC and #3
• Children’s toys
• Cosmetics
• Nail polish
• Perfumes
• Almost anything with fragrance
• Detergents
• Solvents
• IV tubing

There is no easy way to tell if a product has added phthalates. There are numerous compounds and are identified on labels often as acronyms (BBP, DBP, DEHP, DEP, etc). Dust may also contain phthalates so consider washing your hands before preparing food and eating, cleaning your floors regularly using a wet mop and using a vacuum with an HEPA filter. 


Solvents
A meta-analysis in 2012 reviewed research studies that explored the potential link between exposure to solvents and autoimmune disease. Common routes of exposure to organic solvents include:

• Nail polish
• Nail polish remover
• Perfumes
• Dry cleaning
• Paint thinners
• Spot removers. 

Many of the studies the authors reviewed look at occupations that have a higher exposure risk such as nurse anesthetists, painters, people who frequently use hair dye and nail polish, and textile workers. Their findings indicate that organic solvent exposure is a risk factor in developing autoimmune disease. The researchers recommended that people with genetic risk factors avoid organic solvents. I think it might be wise for all of us to avoid organic solvents as much as possible.

I find two free apps helpful when trying to avoid chemicals in the products that we use daily,  Think Dirty and ‘Healthy Living’ by The Environmental Working Group. Both apps contain a barcode scanner so you don’t have to memorize the thousands of chemicals that might be a concern for you- you can just scan the barcode and see the product's score. 

There are so many more chemicals we could talk about in relation to autoimmune disease but instead I want to finish this article with some ideas to support healthy detoxification.


Our detoxification system is quite complex and the major players are our liver, kidneys and GI tract. Our liver processes not just the chemicals we are exposed to daily but also things we produce naturally such as hormones and bilirubin. Some of what the liver processes goes back into our bloodstream to be filtered through our kidneys and excreted through our urine. Other substances are deposited into bile to be dumped into the intestines. Our liver produces roughly 3.5 cups of bile every day! Here is an important piece- when that bile binds to fiber it leaves our body through our stool. Regular bowel movements are a very important part of our detoxification system. Laxatives are not the answer, a healthy diet rich in fiber is!
 
Some practical ways to enhance your natural detoxification process include:

• Drink ½ body weight (lbs) in ounces of water daily
• Consume a diet rich in vegetables, especially vegetables in the brassica family such as broccoli, cauliflower, cabbage, and brussels sprouts.
• Get your body moving. Physical activity moves our lymphatic system which helps remove waste. Bonus if you work up a nice sweat!
• Eat 25+ grams of fiber daily. Excellent fiber sources include legumes, avocado, chia, flaxseed, artichoke hearts and oats.
• Have 1 bowel movement per day. If you struggle with constipation consuming adequate fiber and water is a good place to start.

We are all exposed to chemicals on a daily basis. So I recommend taking small steps to both reduce your exposure to chemicals and support your natural detoxification system. 



References:
Toxicology of Autoimmune Diseases
Organic solvents as risk factor for autoimmune diseases: a systematic review and meta-analysis
A Potential Link between Environmental Triggers and Autoimmunity 
Exposure of the U.S. Population to Bisphenol A and 4-tertiary-Octylphenol: 2003–2004
The Potential Roles of Bisphenol A (BPA) Pathogenesis in Autoimmunity
DINP aggravates autoimmune thyroid disease through activation of the Akt/mTOR pathway and suppression of autophagy in Wistar rats

Authored by Dr. Barrett

This is part five in a series covering autoimmune disease. Don’t miss upcoming articles covering environmental medicine and mind body medicine. Check out previous articles covering Loneliness, GI health, nutrition part 1 and nutrition part 2, and hormones.

Autoimmune disease develops when the immune system starts attacking your own tissues. In addition to genetic factors environmental triggers including viruses, bacteria and other infectious agents play a major role in the development of autoimmune diseases. There are several mechanisms behind these triggers that include but are not limited to molecular mimicry, bystander activation and epitope spreading. If you scroll to the bottom of this blog there are some citations that go into great detail about how these mechanisms work if you are interested. In an oversimplified nutshell there can be cases of mistaken identity, our immune system getting overexcited, and chronic inflammation. 

What is a chronic infection? All of us are likely familiar with an acute infection: you become briefly ill such as from a cold or the flu and then you recover. Acute infections give our immune system practice. I don’t know about you but it’s now been over 12 months since I’ve had an acute infection (thanks physical distancing!)  While this is a nice perk of the pandemic it’s not great for our immune systems. A chronic infection happens when the body can’t seem to muster enough of a defense to adequately resolve the infection. Some examples include hepatitis C and HIV. HIV is treatable but at the time I am writing this there is no way to completely resolve the viral infection. Hepatitis C used to be a lifelong infection but with recent advances in drug therapy it’s now possible to be virus free! Some infections can be latent which means you become ill when initially exposed but then the infectious agent remains in the body dormant only to reactivate at a later time. The classic example is the virus that causes chickenpox will remain latent for decades only to emerge during a time of stress as shingles. Another example of a latent virus is the herpes simplex virus which can cause cold sores or ‘fever blisters’. The herpes family of viruses actually ‘sense’ when stress hormone levels rise and activate to come out of latency. Then the virus triggers a hormone cascade to actually further raise the levels of stress hormones. It’s genius and of course not great for us. There are many pathogens that can be latent or chronic. 

When treating autoimmune disease we are always looking for the root cause(s). We can use symptoms as clues that there may be a chronic infection to deal with. Some of those symptoms include; low grade fevers, migratory joint pain, recurrent hives, muscle pain, crawling sensation, as well as exacerbation and remission of symptoms. We can also use the knowledge of which pathogens are commonly associated with particular autoimmune diseases. For example, the bacteria klebsiella is implicated in the development of ankylosing spondylitis (AS), an autoimmune joint disease impacting the spine. Antibodies against klebsiella are found in AS patients. AS patients tend to have elevated levels of klebsiella in their stool and reduction of this bacteria can reduce the severity of AS. A combination of signs, symptoms and empirical knowledge will lead us to suspect chronic infections. 

Unfortunately, testing for chronic infections is challenging. Sometimes standard lab work can provide clues. We can see chronically low or high white blood cells and/or a chronically low/low normal RDW on a CBC. When testing for specific infections we must look for antibodies specific to that infection. This requires running several tests for each infection you are looking for. Let’s use Epstein-Bar (EBV) as an example. When looking for this infection we will often run: EBV viral capsid IgM, EBV viral capsid IgG, EBV nuclear antigen, and EBV early antigen IgG. If we want to test for other viral infections we will need a similar list of labs. You can see the list of labs gets very long and it can become incredibly expensive. 

Once I suspect a chronic infection the first steps I take are to support the person as a whole. All of us are exposed to infectious agents that can cause chronic infections. Instead of jumping to herbs/medications that can eradicate the infection I first want to identify what about this patient is allowing this infection to persist. In Naturopathic medicine we use the language ‘terrain’ to describe the environment in the host (patient). We need to make the terrain more inhospitable, strengthen the patient, and then go after the infection. 

The following are some avenues we explore together in strengthening the patient and creating an inhospitable terrain: 

• Getting blood sugar in check
• Optimize nutrition
• Making sure stressors and more importantly the stress response is under control
• Prioritizing rest
• Ensuring adequate sleep
• Optimize GI health and the microbiome

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I will leave you with an example from Hashimoto’s disease, a condition I treat frequently. People with Hashimoto’s Thyroiditis (HT) have higher levels of EBV viral capsid IgG and early antigen IgG. In one study researchers looked at surgical specimens of thyroid tissue and found that 34.5% of the tissue from HT patients contained signs of EBV etiology. Does this mean that I test every Hashimoto’s patient for EBV during the first visit? No. We start with the list above while monitoring thyroid function and antibodies. Remember it’s not about the bug, we must work on the ‘terrain’ first and then go after chronic infections. 




References:
Infectious diseases and autoimmunity
Molecular Mimicry, Bystander Activation, or Viral Persistence: Infections and Autoimmune Disease
Virus infection, antiviral immunity, and autoimmunity
Role of Chronic Bacterial and Viral Infections in Neurodegenerative, Neurobehavioral, Psychiatric, Autoimmune and Fatiguing Illnesses: Part 1 and Part 2
Social stress and the reactivation of latent herpes simplex virus type 1
The relationship between Klebsiella infection and ankylosing spondylitis
Study of Epstein–Barr virus serological profile in Egyptian patients with Hashimoto’s thyroiditis: A case-control study
The role of Epstein-Barr virus infection in the development of autoimmune thyroid diseases

This part three in a series covering autoimmune disease. Don’t miss upcoming articles covering chronic infections, environmental medicine and mind body medicine. Check out previous articles covering GI health, nutrition part 1 and nutrition part 2. ​

Hormone balance can often be an overlooked part of autoimmunity. I see a lot of emphasis on GI health (rightfully so) but autoimmune diseases are complex so it makes sense that the etiology is also complex.

A hormone is a signaling molecule released into circulation to target distant organs and regular physiology or behavior. In layman’s terms hormones are tiny middle managers running around the body bossing organs and tissues around. Hormones are involved in most of the activities of our bodies including digestion, sleep, stress, growth, reproduction and mood - just to name a few. We have somewhere upwards of 50 different hormones in the body with varying degrees of relationship to autoimmune disease. I am going to pick a few to highlight for you. 

Estrogen
Autoimmune disease in general tends to target people with ovaries.* A current hypothesis is that estrogen might actually enhance the inflammatory process of the immune system (1). Interestingly, even the joint fluid in RA patients contains higher levels of estrogen regardless of sex (2). I will cover this more extensively in the upcoming article on autoimmune disease and environmental medicine but I want to note that we are exposed to many chemicals that are ‘estrogen-like’ (xenoestrogens) such as BPA. So it’s important to test your individual hormones as well as look at what endocrine disrupting chemicals you are exposed to in your environment. 


Prolactin
Prolactin’s major role in the body is to stimulate lactation and suppress reproduction. Prolactin also stimulates the immune system as well as enhances the production of immunoglobulins and autoantibodies (3). Elevated levels of prolactin have been noted in Lupus (SLE), Rheumatoid arthritis (RA), Sjogren’s, Hashimoto’s and Multiple Sclerosis (MS) (4). Prolactin levels tend to be higher in folks with ovaries. Prolactin also elevates during chronic stress (5). Prolactin is an inexpensive blood test.

Testosterone 
Testosterone levels are naturally higher in folks with testes, which might have a protective effect against autoimmune disease. The effects of estrogens on immunity have been extensively studied but less is known currently about how androgens such as testosterone impact the immune system. We do know that mice with autoimmune disease have an increase in disease activity when they are castrated (ouch!) and androgen treatment improves survival in mice with Lupus (6).

It’s important to look at the pathways. If you have a patient with low testosterone and elevated estrogen they might be converting their testosterone into estrogen via aromatase. So reducing aromatase activity is a better treatment plan than just replacing testosterone. 

Cortisol
I will cover cortisol extensively in an upcoming article on mind-body medicine and autoimmune disease. In a nutshell, cortisol is supposed to be released in short bursts when we are under acute stress (running from a bear for example). Our bodies were not designed to be bathed in cortisol which is all too common these days. We have pesky chronic infections lurking behind the scenes just waiting for our immune system to be suppressed. Epstein-Barr Virus (EBV), varicella and herpes all contain stretches of DNA that sense cortisol levels and when these levels are elevated, the viruses reactivate (7). These viruses are implicated in autoimmune disease, especially EBV (8). 


I like to use a combination of blood, saliva and dried urine (DUTCH) hormone testing to get an overall picture of hormone balance. Hormone pathways are complicated as you can see by this chart below. Just looking at a blood estrogen level isn’t enough. You can have a ‘normal’ estrogen level but if you are converting most of your estrogen into 16-OH that can make autoimmune disease worse. Testing is key. 
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