 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation Addiction and Co-occurring Disorders Part 2, The Physiology of Addiction and Mental Health Issues. Over the next hour, we're going to discuss, somewhat generally, because there's a lot of stuff to go over, neurotransmitters, which we've talked about some before. But then we're also going to talk a little bit more today than we've talked in the past about sex hormones, thyroid hormones, and stress hormones, and how all of those interact in the body to increase or decrease the availability of certain neurotransmitters. We're going to go on from learning about the different hormones of neurotransmitters to discussing the physiology of emotion and motivation. And again, we've kind of covered that, but we're going to go over it real quick again. We'll talk about the physiology of sleep. What happens during sleep and what happens to those hormones and neurotransmitters when you don't get enough sleep? What happens when you eat? Why is eating sometimes rewarding? What happens when people take stimulants, whether it's caffeine or methamphetamine? What happens when we turn up the system and how does that affect the availability of certain neurotransmitters? And then we'll talk about the physiology of depressants. So we're looking in general at what these things do. As far as the physiology of addiction, we're going to talk generally about that right at the very end. So your inhibitory neurotransmitters are those brain chemicals that basically turn down the system. So instead of being hyped up and awake and yada yada, you're calm. You are relaxed. You are maybe even sleepy to drowsy. So your inhibitory neurotransmitters obviously are the ones that kick in or counteract the excitatory ones. Serotonin is your primary inhibitory neurotransmitter. It's broken down to make melatonin and help you sleep. Okay, so we know that one. It's also responsible for a lot of our bowel function, anxiety and also for not it's implicated in nausea and motion sickness. And they found that there are a lot fewer side effects to serotonin antagonists than there are to dopamine antagonists. And we're talking about helping people who have motion sickness and nausea. So anyway, just a little aside there, but serotonin is 80% of it is actually in your GI tract, and it is implicated in bowel function. So when we're thinking about clients who may have an imbalance in serotonin who may have greater pain sensitivity. So I want to start thinking about, you know, how is their GI working, and is, are some of their problems with, you know, stomach problems, pain, irritable bowel that kind of stuff. Is that caused by a serotonin imbalance, or is that causing a serotonin imbalance, or maybe serotonin is not implicated at all and it's something completely different. So serotonin is also implicated in anxiety and aggression if you don't have enough of it, you tend to be more anxious and aggressive because you're not having the turn down, if you will. Low serotonin has also been implicated in poor impulse control. So we really, we like serotonin, but we found, and we're going to talk about that that throughout this class that serotonin has often been given the said or been implicated for a whole lot of things. And we've said, okay, if this happens, then it's low serotonin. If this happens, then it's low serotonin. And as it goes, but no, the research is actually finding that that's rarely true, that most of our problems, whether it be GI problems or mental health problems or addictive issues don't necessarily involve serotonin at all. There is a subset of people for whom it does, but the majority of people, which is why antidepressants are ineffective for about 70% of the population. For the majority of the people, it's not serotonin. So we do want to keep that in the back of our mind. Yes, serotonin is everywhere throughout the body. And the percent of it is in our gut. And our gut is not necessarily going to communicate directly with our brain. We cannot measure neurotransmitter levels effectively in the live human being. Just not how it works right now. There are tests out there that say they can measure your neurotransmitter levels, and that's true. I'm telling you how much of that neurotransmitter is in your gut or in your muscles or wherever versus in your brain. So those tests for our purposes as mental health clinicians and people who come to us who may want to know, well, what antidepressants should I be on? They're not really all that effective. Okay, so depression has really been debunked as being linked to serotonin in the majority of cases. Serotonin is implicated as one of those neurotransmitters involved in pain control. People with lower serotonin tend to have a lower pain threshold. So it hurts more. It doesn't mean that they're sissies or anything like that. It just means that they are more reactive or they feel more pain because they don't have the same level of serotonin and maybe endogenous opioids kind of coursing through their system. Serotonin is also, like I said, involved in sleep. An interesting fact is that alcohol impairs the body's ability to convert tryptophan, which is an amino acid to serotonin. So when you have somebody who's an alcoholic, let's think about how this works. If they are drinking and maybe they're eating a perfectly healthy diet and they just happen to drink a lot. If their body can't convert tryptophan to serotonin, then all of these problems up here that may be implicated by low serotonin can start to rear their ugly head because the body can't make serotonin out of anything else. It has to make it from tryptophan. And if it can't make serotonin, then it can't make melatonin, which is involved in sleep. And you're going to see how important all that is later. So the take home message with that is that alcohol is really something to be considered for moderation, especially if we have a client who is struggling with depression. Maybe they're not an alcoholic, but they need to consider the long term impact if they want to feel better is preventing their body from making using the building blocks to make the neurotransmitters that they may need. Is it worth that drink? And remember that serotonin actually has been found in the research to be implicated in low serotonin is implicated in people with generalized anxiety disorder. So it hasn't been completely then debunked for everything. But researchers and clinicians finally are starting to realize that there are a multitude of reasons that somebody could have a mood issue that somebody could have even low serotonin. Okay, if the person has low serotonin. All right, that's fine, let's address it. But what is causing the low serotonin? And we'll look at that more in the next few slides. Abba is your other major inhibitory neurotransmitter. It has sedative depressive and anti anxiety properties to them. The really interesting thing is and when I say depressive I mean it slows down everything it's not that it makes people depressed, but it's your anti anti anxiety, your natural anti anxiety neurotransmitter. It helps improve concentration by filtering out background noise. So you're able to focus a little bit better when you've got normal levels of GABA. It helps with impulse control. Think about when you're anxious, when you're a little bit revved up when you're stressed out, and somebody scares you, maybe you're a little bit more jumpy. Well, think about if you have GABA at the right levels in your system and you're not stressed out and somebody scares you. Are you as jumpy? Are you as impulsive? A lot of our impulses are associated with wanting to make a threat or a pain go away. So, if you're not perceiving as many threats, you're probably not going to be as impulsive. Another little interesting side thing is that glucose, you know, sugar is necessary for the formation of GABA. So people with hypoglycemia can have a reduction in GABA and an increase in anxiety. So think about if your blood sugar gets low, even if you are not hypoglycemic, but, you know, you got to work, you had back to back patients, you didn't take time for lunch, you had back to back patients, you're on the drive home from the office. Your blood sugar is low. Are you more likely to respond with some anxiety or irritability to things that happen versus when you are well nourished and your blood sugar is kind of stable? For most people, they're going to say, yeah, I tend to be a little bit crankier when my blood sugar is low and shakeier. All right, so those are our two inhibitory neurotransmitters. Glutamate is generally acknowledged to be the most important neurotransmitter for brain functioning, and it's excitatory. It gets you up, it gets you going, it gives you energy, and it's responsible for helping us learn and remember things. So if you've got low levels of glutamate, you know, you might have difficulty concentrating and learning. Now, the interesting thing is that glutamine, which is an amino acid, you eat it, glutamine is converted into glutamate. All right, well, that makes sense. So you eat something, it is turned into this neurotransmitter that's excitatory. The interesting thing is GABA is made by the breakdown of glutamate. So you have, if you have glutamate, then you can have GABA. If you don't have enough glutamate, then you're not going to have enough GABA. So it's a balance, like making a warm bath. And, you know, this is important to remember simply because we want to know what's revving us up and what's slowing us down. Norepinephrine or noradrenaline, depending on where you are, is what they call a catecholamine. It increases arousal and alertness, promotes vigilance and focuses attention. So you're hearing a theme here about attention and memory. It enhances formation and retrieval of memories. So in your norepinephrine, that's your motivation chemical, is secreted. It encourages you to pay attention to remember and to be able to go and file things away and access them really easily. It can also promote restlessness and anxiety if you have too much. So it's all about moderation. When I talk about too much or too little of a neurotransmitter, everything is always in relation to all of the other neurotransmitters and hormones. So we can't just necessarily get a measurement and go, well, you've got too much of this. Well, we have to know what the levels of everything else are. It would be kind of like making a marinara sauce and saying a teaspoon of garlic is how much you need. But that teaspoon would be enough if you were making maybe two quarts of marinara sauce. But if you were making four gallons, all of the other spices and everything would be in much larger proportions. So would a teaspoon be enough. So we need to know what proportions all the other chemicals are at in order to know how much we need. And since we can't measure them, we're just kind of left guessing. Dopamine is another catecholamine and it's broken down to make norepinephrine. Now, normally we think of dopamine as our pleasure reward chemical, which it is. Don't get me wrong. That's what it's there for. And it tells us I want to do that again. But it's broken down to make our focus concentration motivation chemical. Interesting. So we need dopamine in order to make norepinephrine. We need norepinephrine to want to get up and go. So if we are draining our dopamine system through addictive behaviors or some other reason, guess what, we're not going to be able to make enough norepinephrine. Or those receptors that usually receive the norepinephrine and the dopamine are going to be basically unresponsive, and you're going to knock on the door and nobody's going to open. So dopamine is broken down to make norepinephrine, which is your motivation chemical, high levels of dopamine in the brain generally enhance mood and increase body movement. So dopamine may produce nervousness, irritability, aggressiveness and paranoia. So think about cocaine. If somebody takes a whole lot of really good cocaine. This is probably what we're going to see, because the levels of dopamine in their brain just skyrocketed. And everything else didn't catch up. There was no signal to all the other chemicals to go okay we're going to have a surge here. So we have all of those neurotransmitters that are responsible for helping us feel happy. Serotonin helps us feel theoretically calm and content and focused. GABA is an anti-anxiety medication or not medication but neurotransmitter. And then dopamine, glutamate and norepinephrine are all of our excitatory ones. They're the ones that get us, guess what, excited, happy excited, mad excited, whatever the excited is, they rev us up. And that's what we label with our emotional feeling states. So what is this HPA access thing that I talked about every once in a while. It allows us to stress the level of various hormones change and reactions to stress are associated with an enhanced secretion of a number of hormones, including your glutaco corticoids, which is cortisol. Your catecholamines to increase mobilization of energy sources which is blah, blah, blah, blah, blah, you get stressed, your body sends out the message that we need some energy, we need some fuel for this fight or flight response. Cortisol is activated and it's a glutaco corticoid, which tells your body we need to prepare, we need to get some glucose going. So we've got energy for this fight or flight thing. Catecholamines, adrenaline and dopamine are released. That's your body going, okay, we have this energy, now let's get the team revved up. The other thing that happens though, is your gonadotropins are suppressed, your body goes, you know, we don't really have time for sex right now, so let's not worry about it. So your sex hormones tend to be suppressed under high stress levels. Okay, well, who cares, you're going to find out in a little while that that's kind of a big deal, because there is a strong relationship between the amount of and the balance of our sex hormones and the availability of serotonin, norepinephrine and dopamine in our bodies. Oh, well sweet. Here we are. Androgen or testosterone. What we want to look at is what does it do? It helps us with concentration, mood, and not enough of it can result in an increase in belly fat. They found that in men, depending on the research that you look at somewhere between 30 and 40 years of age, they start losing somewhere between 1% and 1.5% of their testosterone each year. And so you're thinking, well, you know, that's not that much, but you've also got to remember that everything's in a balance, so they're losing their testosterone, but what else is not decreasing? Estrogen. So some articles have kind of termed it manopause, if you will. The increase in estrogen can increase irritability, difficulty concentrating and belly fat, as well as gyneomastia or development of excess fat in the breast area. So something interesting to look at, if you're dealing with patients, male patients who are over the age of 40, who are having suddenly, if you will, depression or anxiety issues or are talking about their midlife crisis, that those, all of those things could be precipitated by changes in their neurochemistry because of a drop in testosterone. Not necessarily, but it's one positive or one possible reason. Estrogen, believe it or not, is a neuro stimulant. Estrogen revs us up. Receptors for estrogen are very abundant in the emotion center of the brain called the amygdala and the hypothalamus, which is involved in what we just talked about, the HPA axis, which tells us to fight, flee or freeze. Estrogen increases serotonin receptor responsivity, increases the number of serotonin receptors in the body and enhances serotonin transport and uptake. So we might hypothesize, and we don't know any of this for sure, that if someone's mood disorder started or fluctuates in response to fluctuations in their estrogen, then there might be a serotonin component to this mood disorder because estrogen is so intimately connected with serotonin availability. High levels of estrogen are associated with anxiety. One thing that they found in American culture and industrialized nations, but especially American culture, is we have a lot of chemicals and stuff that we eat that tend to, and habits that we do that tend to increase our levels of estrogen, creating something called estrogen dominance. But high levels of estrogen are associated with anxiety. So one thing clients may want to do, especially female clients, but you know, if you have a male who is feeling like estrogen may be increasing too much. Have them look at what they're doing as far as lifestyle factors to see if there's anything that might be increasing their estrogen levels. Low levels of estrogen are associated with depression because there's not enough serotonin going around, but also because estrogen is a neuro stimulant and if it's not there, then there's no stimulation. So all right, so now we're looking at, first we started implicating just neurotransmitters and going, well, if you don't have enough of this or too much of this, then you might be depressed. Well, now we've added to the mix and said, well, guess what, these imbalances over here in the neurotransmitters may be caused by something completely different, such as sex hormones. Progesterone is another sex hormone. An imbalance in the ratio with estrogen is implicated in mood disorders. So progesterone kind of calms down estrogen, they're yin and yang, if you will, kind of like GABA and glutamate. It's referred to as the relaxation hormone. The interesting thing here is synthetic progesterone, which is present in a lot of birth control is associated with depression. Whereas naturally occurring progesterone levels haven't had that same association drawn in the research literature. So another thing to look at with our female clients is possibly to ask them, if they're presenting with depressive symptoms, have they changed their birth control regimen? Or have they recently gotten pregnant or had a baby or stopped nursing? And that was one I learned, you know, when I stopped nursing my first child was your body actually maintains different levels of hormones. It makes sense, maintains different levels of hormones when you're nursing. So you're producing milk and stuff. And then when you stop nursing, there's a whole different hormonal cascade that happens. So there are multiple different times that estrogen can change and progesterone levels can change. Ganatotropins, hormones synthesized and released by the anterior pituitary promote the production of sex hormones. So remember earlier, I said that when we're under stress, our body releases cortisol and cortisol tells our body, you know what, we don't need to produce those sex hormones right now. So let's connect it all. If you're under a lot of stress, you may not be producing enough estrogen, which is why a lot of women when they're under a lot of stress tend to have more erratic cycles. But even in men, when your sex hormones are not being produced because your body's focused on fight or flee, it makes the availability of serotonin and norepinephrine and dopamine less available. So chronic stress can alter the availability of sex hormones, which altered the availability of neurotransmitters. Okay, you wanted some good news. We got some good news. Oxytocin is our bonding hormone, and they found that it can counteract cortisol and vice versa. It's not just getting a hug, though. So I mean, hugs are great. Don't get me wrong. But a lot of research has indicated that people who have companion animals and pet their companion animal, it can be a horse, it can be a dog, it can be a cat, a bunny rabbit, whatever it is that does it for you, where you feel that sensation of bonding. 15 minutes of petting that animal raises oxytocin levels, and which counteracts cortisol. Sweet. Thyroid hormones, yet a whole other category. So we're moving off of the sex hormones onto our thyroid. You have two types of thyroid hormones, thyroxin and the other one that I can't pronounce. T4 and T3. T4 is broken down to make T3. They are always in a balance. They're always in a ratio. Too much thyroid hormone, which typically is T3, speeds things up and too little slows things down. So think about somebody who's hypothyroid. They have symptoms of depression. One of the things we want to rule out early on with our patients who present with depressive symptoms is thyroid problems. The patients with too much thyroid hormone may present with anxiety symptoms. So again, we want to look and say, is there a physiological cause to the neurotransmitter imbalance? The pituitary gland, hypothalamic pituitary adrenal axis, so this is the middle of that stress axis here. The pituitary gland releases thyroid stimulating hormones to get the thyroid to release T4 and T3. The majority of the thyroid hormones produced by the thyroid are T4, but T3 is the most usable form. So it sends out T4, which is kind of, you know, it's just kind of there. It's not a real hard worker at all. But along the way, it gets converted to T3, which is a workhorse. This conversion is the critical element because a lot of times doctors will test thyroid secreting hormone and T4 alone. And they'll say, well, you're secreting enough and there's plenty of T4 to be broken down to T3. So I don't know why you have hypothyroid symptoms. But the piece that they're missing is they may not be, we may not be adequately converting T4 to active T3. So it's important if you think you have thyroid issues going on to work with an endocrinologist who's going to do more than just a superficial test. Or if you go to a GP, you have, and they do just a TSH-T4 test comes back normal, but you're like, no, something's not right. There are more tests that can be done to be more specific about what's available. Because if we've got a client who goes to the doctor and says, Doc, you know, I feel awful. I can't wake up. I've got no energy. They run these tests. They say, well, there's nothing wrong with you. That just disempowers the client. The client's going, well, nothing's wrong with me. I don't know why I feel this way. I have no hope for getting better because I don't know what's wrong. So I want to make sure that we educate them about all the possible things that they might be able to look into. I don't dump all this on my clients at first. You know, when I go through the assessment, I start listening for things and then I encourage them to get a full blood panel done. And then we talk about all that when they come back and then narrow it down to other things that they may want to look at further testing for if the general assessment didn't come back with anything. Overactive thyroid produces anxiety, feelings of nervousness, butterflies, heart racing, trembling, irritability and sleep difficulties. Underactivity, depressive symptoms. The other interesting thing, and I don't know what other word to use, is if it's either overactive or underactive, the person can have mood swings and have sleeping difficulties. So we don't want to just say, well, you're having mood swings, it must be hyper. We don't know. So we want to look at maybe the thyroid gland is sputtering and giving a little bit and then not enough and then a little bit and then not enough. It's just important for them to understand what the thyroid hormone does. Other cognitive issues, difficulties with concentration, short term memory lapses and lack of interest and mental alertness are also common in hypothyroid. But they're also common in a whole bunch of other things. I mean, most of these sound like what the criteria for depression. So we're trying to sort through and figure out what may be going on with that particular client. Thyroidism led to a significant decrease of responsiveness of the serotonin system. So again, here's something else. If you don't have enough estrogen or if you don't have enough thyroid, the serotonin system may be implicated. And we know that serotonin insufficiency is implicated in generalized anxiety disorder. So one of those little paths to kind of be aware of optimal thyroid function may be necessary for optimal response to antidepressants. Antidepressants mean the serotonin is still there. But if estrogen and thyroid are responsible for transporting it around and making sure it gets taken up in the right places, then if those two systems aren't working, no matter how much serotonin is in the system, if it's not getting to the right places, it's not going to do the job. Hypothyroidism generally increases enzyme activities and GABA levels. Now you may go, well, sweet, we want more GABA, but we don't. Too much GABA has too much of a depressive effect, so the person may not be motivated, may feel apathetic about things. They can't get excited about anything. So there is such a thing as being too chill. Thyroid hormone plays a role in the output of dopamine. The precursor to norepinephrine are motivation chemical. Not enough thyroid hormone, not enough excretion of dopamine, not enough get up and go. And norepinephrine has also insufficient norepinephrine has also been implicated in depression. So serotonin is not even in there. We're talking about thyroid, dopamine and norepinephrine. Stress hormones. So we've moved on. Cortisol. It's released from that HPA axis. Cortisol triggers a decrease in leptin and an increase in ghrelin, which increases appetite and food intake. Cortisol is telling you there is a threat. We need energy. We need to mobilize the sugars because it's a glutaco-corticoid. But we also need to get more sugars in here. So we have energy for the fight or flight as long as it goes on, which is why a lot of people who are chronically stressed also feel like they're chronically hungry. They're just like, oh, I'm famished all the time. And it may not be that their body needs all that energy, all those calories right now. Their body may be hoarding it because they think it's going to have to fight or flee for a long time. Cortisol also affects the endocrine system, including thyroid, insulin, regulating blood sugar, and your sex hormones. All right. Well, that's not good. So when people are stressed, they maintain higher levels of cortisol. When they maintain higher levels of cortisol, basically every bodily system and all the neurotransmitters are impacted. Adrenaline is another stress hormone. You know, we think about it when somebody gets really upset or excited or whatever. They have a rush of adrenaline. All right. Thyroxin is also released from the kidneys and are from the thyroid and helps you get fatty acids, which are long term, long term energy. Fat has nine calories per gram. Sugar has four calories per gram. So fat is a much denser source of energy. Effective chronically elevated cortisol includes impaired cognitive performance. You're not thinking as well. Dampened thyroid function. Yep. Eventually the body goes, there's no point. The stress is not going to go away. There's no point in continuing to fight. So I'm going to turn down the sensitivity of the symptom. Blood sugar imbalances, sleep disruption, elevated blood pressure, lowered immune function, and increased abdominal fat. So if a client starts talking about how they're stressed, they're hungry all the time and they keep suddenly gaining all this weight in their belly, we might start looking at chronic stress and interventions that we might use for chronic stress, including mindfulness, meditation, exercise, you know, anything that we can throw their way in addition to having them get a full physical to make sure there's nothing else going on like, you know, actual hyperhypothyroid caused by a physiological problem. Low levels of cortisol, brain fog, cloudy headedness, mild depression, low thyroid function again, blood sugar imbalances such as hypoglycemia. And remember when you've got blood sugar imbalances and not enough sugar, then your body cannot produce enough GABA, which means you're not going to have enough naturally relaxing chemicals. Fatigue, especially morning and mid afternoon, sleep disruption, low blood pressure, lowered immune function and inflammation. So these are all things that we can produce to our clients to say cortisol, it's not public enemy number one, but it's pretty close to it. So let's look at how your cortisol levels, how your sustained chronic stress might be impacting your mood, your health and your sleep. And think about different ways we can reduce that because that's more tangible and cortisol is measurable. Obviously the doctor has to do that, but it is measurable. In general, when we feel emotions, a stimulus is received by our peripheral nervous system. The brain responds by triggering the amygdala, which is our emotion center. And the hypothalamus assesses, if you will, the need for fight or flee, it goes there's a threat or there's not. Emotional memory helps the brain determine the types of neurochemicals to secrete and in what amounts. If the hypothalamus goes, yeah, no big deal, then you're going to have more inhibitory neurotransmitters than if you have your hypothalamus going, that's a problem. What we need to look at, and this adds another layer, is when there is too much of a chemical or hypersensitive receptors. So hypersensitive receptors are like the person that you know that jumps when you tap them on the shoulder, somebody who's hyper vigilant. When they are activated, they go from zero to 100 and it's just like insensitive receptors on the other hand. When they're activated, they may not do anything at all. So you may have enough chemical in the system, but if the receptors are not receptive, then the chemical can't do its job. So if serotonin is sitting outside the receptors door just kind of knocking on it going, let me in, and that door never gets opened, then it doesn't matter how much serotonin is sitting in the synapse, it's not going to do any good. So as I said before, every time I talk about too much and too little, it's always relative to the proportions of the other hormones and neurotransmitters for that person. Anxiety, irritability, and anger are fight or flight response can be caused by, dot, dot, dot, too little serotonin, where you have anxiety coming on because serotonin is not there to help the person calm. Too little GABA, again, not enough calming. Too much norepinephrine, too much estrogen, too much testosterone, or too much thyroid. So any of these too much is going to cause one symptom, either anxiety or irritability or anger, and too little will probably produce something more on the depressive continuum. Now happiness and excitement is an interesting one because happiness and excitement are excitatory neurotransmitters. They're going to get your heart rate going, they're going to get your blood flowing, they're going to get your breathing a little bit faster. Think about Christmas morning when you run down the stairs in order to see what's under the Christmas tree or something else that is really exciting. Your body's secreting dopamine, norepinephrine, glutamate, and maybe a little bit of serotonin in there, but these are the same chemicals that are going out during a stress response. It's how the amygdala processes everything. So we still need these excitatory neurotransmitters. We can't just shut them down and go, well that's causing too much problem. Let's turn it down. Well, if we turn it down, we're also turning down the body's ability to respond to happy stimuli. And like I said, depression can be caused by serotonin insufficiency or excess. And why is it excess? When you have too much serotonin or too little serotonin, you can have high levels of anxiety they found and high levels of anxiety trigger the stress response system. After a certain period of time, the stress response system goes, you know what, I can't stay this hyped up for this long. I've got to turn down my sensitivity. I've just got to, you know, let it all go, which starts leading to feelings of apathy and depression. It can be caused by norepinephrine insufficiency, dopamine insufficiency, thyroid insufficiency, or again, too much or too little estrogen. The good thing is thyroid and sex hormones can be measured so we can easily or somewhat easily help the person rule those in and or rule those out as can cortisol. So if they have chronically elevated or chronically low levels of cortisol, they're going to have some mood symptoms. But we can figure out that that's going on and we can help educate the patient to why they're having the symptoms they are. It's not all in their head. The New England Journal of Medicine on major depression said numerous studies of norepinephrine and serotonin in plasma urine and cerebrospinal fluid, as well as postmortem studies on the brains of patients with depression. So we're talking about humans, not just rat studies have yet to identify the purported deficiency reliably. So while we're talking about depression being caused by, if you will, norepinephrine or serotonin deficiency, there's no real research that can reliably say yes, this is it 100% of the time, or even 95% of the time. It's more like, yeah, 15% of the time. So yes, deficiencies in norepinephrine and and or serotonin do cause depressive symptoms in some people. But that is a small subset, and they found that there are 20 or 30 small subsets of different causative factors estrogen and progesterone modulate sleep, and too much estrogen can cause insomnia. So again, if you have too much estrogen, while you may have plenty of serotonin going on, you also may not be able to sleep. Sleep deficiency promotes elevated cortisol and further disrupts our feeding hormones. Now for cortisol elevated, we're not going to get good restful sleep. Sleep deficiency is related to a 30% reduction in thyroid hormone levels. So again, remember that the body finally after chronic stress will start turning down the thyroid is just like there's no need to exert any more effort because this is a losing proposition. With sleep deficiency, the thyroid hormone levels go down cortisol levels go up, which is your stress chemical. So everything's starting to get out of whack. When people eat serotonin suppresses appetite and increases with feeding. So as we eat, our serotonin levels go up, especially if we're eating carbohydrate rich foods, but anytime we're eating. So if there's not enough serotonin people's appetite suppression may be off. But that's also one of the reasons that people eat for comfort is because serotonin helps them feel a little bit better. So when they're eating serotonin goes up. Dopamine is associated with satiety satiety, which is great. But if you don't have enough dopamine, then you may never feel satisfied. As we talked about before cortisol increases appetite. The neurons involved in the regulation of feeding are located in the hypothalamus. So when you've got that hypothalamus pituitary adrenal axis, all activated all the time the HPA axis, your feeding is going to be probably way up here, because the hypothalamus is going there's a threat we need food we need we need energy. And all of these chemicals are involved in the stress response. Stimulants set off the stress response system by causing the body to kind of dump, if you will, thyroid hormones stress hormones and suppress sex hormones. You know that HPA axis gets activated. Excited during neurotransmitters, dopamine and norepinephrine gets secreted. So if you've got a lot of pleasure reward focus and concentration going on. And you're just like woohoo. Yeah, you're probably going to want to do that again. But when that wears off, when stimulants wear off, they wear off a whole lot faster than what our normal neurochemicals would normally do. So when they wear off, there's a sudden lack of stimulation pleasure and reward. And there's an excess of GABA and other other neurochemicals when people drink alcohol. Initially, GABA goes way up when they drink the alcohol and they feel relaxed and disinhibited and all that kind of stuff. When the alcohol wears off and all of a sudden in proportion to everything else, there's way not enough GABA. So anxiety goes way up. What we want to remember is when we're taking substances or engaging in, well, taking substances specifically, they are going to take effect and wear off in a much different rate than what would happen from our body normally excreting or causing those neurochemicals to be excreted. Depressants increase GABA and may increase serotonin. So they found that alcohol may increase serotonin. It also increases GABA. But again, when it wears off, you got a big problem. There are other depressants out there besides alcohol though. So it's important to know, what are your clients taking? What are they using recreationally? Not to be judgmental. You know, if you have a couple drinks in the evening, it is what it is. What other things are you taking? Are you using? Including looking at herbs like valerian. Valerians are pretty powerful depressant. So it's important to know what they're taking so they know what impact it's having on their body. There are a variety of neurotransmitters that are implicated in moods. Sex, stress and thyroid hormones, among others, modulate the secretion and absorption that is modulate the availability of these neurotransmitters. So if there's a lack or an insufficiency proportionally speaking of norepinephrine, what we want to ask is not how do we increase it, but what's causing it? Why is there an imbalance in norepinephrine in this particular patient? dysphoria is about having an imbalance, not necessarily too much or too little. You may have too much X in relation to Y, too much glutamate in relation to GABA. So talking with your clients, if they start taking medications, talk with them about how they feel and whether it's getting worse or getting better to help understand, you know, are we targeting the right things here? Sleep deprivation directly contributes to alterations in hormone and neurotransmitter levels and excessive eating may be caused by high cortisol levels because the brain thinks it needs to store energy for the long fight. Sex hormones impact the availability of serotonin, but oxytocin has been shown to inhibit cortisol. So pet a dog, get a hug, do something to promote bonding. It will help with stress levels. Dysphoric moods are caused by a neurotransmitter imbalance, but what causes that imbalance in each person varies greatly, and they found it even varies greatly among people with PTSD. So just like depression, PTSD does not have one simple cause. A cascade effect can happen when any one of these systems goes offline. So if the thyroid system goes offline has a dysfunction for some reason, it may negatively impact all the other symptoms because it's going to change the balance and the ratios of all the other hormones and chemicals involved in those feedback loops. So final thoughts. Chronic stress impairs sleep, which causes imbalances in hormones and neurotransmitters involved in eating, sleeping, mood, attention, motivation and sex. Disruptions in nutrition can fail to provide the building blocks for the hormones and neurotransmitters. So it could be something as simple as, you know, eating junk food every day. Sleep impairment is associated with decreases in thyroid hormones, increases in cortisol and dysregulation of eating. So if somebody's hungry all the time, but they've got low mood and, you know, they present with depressive symptoms, we may want to look at what's going on and could it be a factor contributing to this is sleep. But any of these things could also contribute to problems with sleep. Estrogen and testosterone imbalances can cause depression or anxiety like symptoms and thyroid hormone imbalances can also cause depression and anxiety like symptoms. So the take home message is this stuff is really stinking complicated. But what we know is everything is intimately interconnected. So we don't want to just start by saying well it sounds like you've got this and try to pigeonhole everybody into one particular causation we really need to understand what's going on with them. And since we can't measure brain neurochemicals to figure out exactly which ones out of whack. That's where the part art comes into psychology as part art and part science. Okay, so are there any questions. Think you're all probably feeling like me what after I wrote this. I worked on research for about 20 hours, and I was all but drooling on myself by the end I was like really. I tackled a pretty deep subject for an hour. And you may need to go back and look at the presentation to kind of make all the connections and connect the dots. As it applies to your clients but let's see. Thinking about autism symptoms. And these issues and body functions and hormones. Yeah, I mean certainly autism is correlated and I'm pretty ignorant as to the neuro physiology of autism. But I would think that there's a strong correlation with the neurotransmitters so I would look at other systems to see if there's something that's going offline. That may be contributing to the neuro neurotransmitter imbalance when symptoms are exacerbated. Which makes me think, you know, again, I don't know as much, I don't know much about autism. But when a client begins stemming, I'm wondering if those impulsive behaviors, I mean obviously there's high levels of anxiety at that point so I'm wondering what's happening with the stress response system and the GABA feedback loop. I would love after you guys kind of digest this and stuff. If you have any thoughts, reactions, connections, I would love to hear back from you. I'll put my email type. And other than that, have a wonderful amazing weekend and I will see you on Tuesday. This episode has been brought to you in part by AllCEUs.com, providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists, and nurses since 2006. Use coupon code COUNSELORTULEBOX to get a 20% discount off your order this month.