The diagnostic and statistical manual of mental disorders (DSM-5) is the most current edition of the guidebook for psychiatrists and psychologists who follow a diagnostic framework. Within this book are over 300 classifications for various 'disorders' (e.g., major depression, generalised anxiety disorder, panic disorder), that are determined by an individual meeting a certain number of symptoms over a certain period of time. This manual has built in caveats which are called "rule-outs." These include external factors that are known to produce psychological symptoms for some individuals. Those trained in using DSM-5 learn a process of 'differential diagnosis,' which considers several possible alternative explanations for symptoms ("rule-outs"), before making a formal diagnosis and recommendations for treatment.
Examples of "rule-outs" are substance-induced or medication-induced mood, anxiety, psychotic, or other disorders. When a substance is suspected, a period of abstinence from it is recommended, and symptoms monitored to see that resolution occurs. A common example of this is alcohol. For some individuals, alcohol use will cause or exacerbate low mood (i.e., alcohol-induced depression). Caffeine or sugar are also substances which may cause anxiety or panic attacks in sensitive individuals. The mere absence of the substance in these cases may lift mood or reduce anxiety, while reintroduction will again bring about symptoms. The good thing about this is that people then always know they have a choice (i.e., if I use X substance then I accept Y consequence).
Other examples of "rule-outs" involve health conditions that may masquerade, in part, as psychological in nature. Common health conditions that can do this are thyroid disease and adrenal dysregulation (both rife in our current societal time). Unfortunately, sometimes these underlying explanations get overlooked - and haven't actually been ruled-out. But possibly the greatest overlooked "rule-out" or contributing factor in psychological presentations is that of nutritional inadequacy or deficiency. This is kind of amazing as the earliest signs of a nutritional problem are psychological (e.g., anxiety, fatigue, cognitive concerns, low mood, and insomnia). Therefore it is logical that people might think to either seek psychological assistance, or see their GP, to enquire about anxiety or mood treatment options (for their nutritional problem).
Why are nutritional inadequacies/deficiencies overlooked as a factor in mental health symptoms for some individuals? Perhaps this is because optimal levels (required for feeling your best) are vastly different from what are considered a deficiency according to most medical reference ranges. Additionally, could it have something to do with the lack of nutritional training in both mental health and medicine? New Zealander's may experience suboptimal nutrition or deficiencies for a variety of reasons. Those at greatest risk are reported to include the following populations - people with chronic illnesses (IBS, chronic fatigue, autoimmune conditions), those taking multiple medications, the elderly, sedentary populations, pregnant and breastfeeding women, vegans/vegetarians, some athletes, those using alcohol and other drugs, and those who are socially isolated (Kotsirilos, Vitetta, & Sali, 2011). The general public can also be affected, because necessary vitamins and minerals are no longer in abundance within the soil we grow food in. Additionally there is a generalised lack of real 'whole' foods consumed as part of the standard (processed and anti-nutrient) NZ diet. The relevance of nutrient dense foods with adequate vitamins and minerals is that these are foundational in both the structure and function of the brain. For example, correlational research has found that both adults and adolescents eating a diet higher in good fats and protein, fruits, vegetables, nuts, and seeds have lower rates of anxiety and mood difficulties (Davison & Kaplan, 2012; Jacka, et al., 2011).
The main reasons for nutritional deficiency to occur in those eating the standard NZ diet can include 1) poor nutrient intake because the diet lacks adequate nutritional content for that person's needs (e.g, insufficient diet, veganism or vegetarianism, poor soil conditions, processed/sprayed foods); 2) good intake of quality food but poor absorption through the gut lining (e.g., gut health issues; low stomach acid); 3) interference with absorption because of 3rd party interference (e.g, tea, coffee, alcohol, or medications interfering with absorption); 4) the guts inability to absorb well due to chronic stress, anxiety, or unresolved trauma.
Particular nutrient insufficiencies that can wreck havoc with mood, anxiety, and energy reserves, as well as cognitive functioning (e.g., memory and concentration), include Vitamin B12 (only available from animal products), broad spectrum B Vitamins, Iron, Vitamin C and D, essential fatty acids, and the minerals magnesium, selenium and zinc. Nutrients work synergistically (together) and so a deficiency in one area may have a domino effect and impact in other areas.
One common deficiency is Vitamin B12, which can present as anxiety or panic attacks, chronic fatigue, memory impairment, neurological syndromes, or low mood. Long-term problems associated with deficiency are as extreme as dementia and pernicious anemia (risking brain, stomach, and nerve damage). Thus, B12 deficiency can become severe and debilitating. Currently there is no universally accepted reference range or clinical cut-off that determines a deficiency using a blood test, which is a rough method of detecting deficiency. Additionally, ranges used in New Zealand are often lower than what research findings suggest are required for optimal functioning.
In New Zealand, unless a persons blood results are below 200 pg/ml they are rarely offered B12 treatment (intramuscular injections or sublingual tabs) in my experience. Yet research finds symptomatic people who score well above 200 pg/ml, and in Japan and Europe those under 500-550 pg/ml will be treated (Dharmarajan, Adiga, & Norkus, 2003; Hannibal et al., 2016; Lachner, Steinle, & Regenold, 2012). When deficiency has been detected (and in my observation, the more generous range of 550 pg/ml should be used if someone is symptomatic) then high dose B12 (e.g., 1000 mcg (1mg) of sublingual methylcobalamin) is suggested, as well as a root cause analysis to understand what is causing the lack of B12. This part is vitally important so that malnutrition or malabsorption can be rectified through diet and lifestyle interventions, or ongoing supplementation (particularly this is necessary for vegans/vegetarians).
Ruling out either single vitamin/mineral inadequacy, like B12, or broad spectrum inadequacies is important alongside any psychological or lifestyle intervention for mental health presentations. Nutritional interventions are relevant for anyone seeing a psychologist and can include 1) education and the provision of relevant resources and research; 2) interventions that help maximise nutritional content (dietary modification or appropriate supplementation); 3) interventions that help minimise interference with gut absorption (e.g., reduction of caffeine and alcohol, working with trained health professionals to assess and heal the gut); 4) and enhancing the bodies ability to rest, repair and digest/absorb from food. This can include all the traditional and well researched psychological therapies such as mindfulness skills, relaxation, addressing past trauma, sleep hygiene, improving interpersonal relationships and connection, and lifestyle modifications.
The aim of this Nutritional Deficiencies Edition was to put a spotlight on micronutrients (vitamins and minerals) as a possible causal or contributing factor in common psychological presentations, including anxiety and mood difficulties. The work of Professor Julia Rucklidge is building on the emerging evidence-base for nutrition as an effective alternative or adjunctive approach to therapy or medication for people experiencing mental health difficulties. There is much work to be continued in understanding how best to use nutritional interventions in mental health treatment. The research base to date is sufficient to conclude that "Nutritional medicine should now be considered as a mainstream element of psychiatric practice, with research, education, policy, and health promotion supporting this new framework" (Sarris, et al., 2015).
Davison, L.M., & Kaplan, B.J. (2012). Nutrient intakes are correlated with overall psychiatric functioning in adults with mood disorders. Canadian Journal of Psychiatry, 57, 85-92.
Dharmarajan, T. S., Adiga, G. U., & Norkus, E. P. (2003). Vitamin B12 deficiency. Recognizing subtle symptoms in older adults. Geriatrics, 58(3), 30-4.
Jacka, F.N., Kremer, P.J., Berk, M., de Silva-Sangigorski, A.., Moodie, M., Leslie, E.R., ...Swinburn, B.A. (2011). A prospective study of diet quality and mental health of adolescents. PLoS ONE, 6(9), e24805.
Jacka, F. N., Cherbuin, N., Anstey, K. J., Sachdev, P., & Butterworth, P. (2015). Western diet is associated with a smaller hippocampus: a longitudinal investigation. BMC medicine, 13(1), 1.
Hannibal, L., Lysne, V., Bjørke-Monsen, A. L., Behringer, S., Grünert, S. C., Spiekerkoetter, U., ... & Blom, H. J. (2016). Biomarkers and algorithms for the diagnosis of vitamin B12 deficiency. Frontiers in Molecular Biosciences, 3, 27.
Kotsirilos, V., Vitetta, L., & Sali, A. (2011). A guide to evidence-based integrative and complementary medicine. Elsevier Australia.
Lachner, C., Steinle, N. I., & Regenold, W. T. (2012). The neuropsychiatry of vitamin B12 deficiency in elderly patients. The Journal of neuropsychiatry and clinical neurosciences, 24(1), 5-15.
Sarris, J., Logan, A. C., Akbaraly, T. N., Amminger, G. P., Balanzá-Martínez, V., Freeman, M. P., ... & Nanri, A. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet Psychiatry, 2(3), 271-274.
World Health Organisation (2008). Conclusions of a WHO Technical Consultation on folate and vitamin B12 deficiencies. Food and Nutrition Bulletin, vol 29, no. 2 (supplement), S238-S246.