Monday, November 7, 2011

Is Some Psychiatric Disease a Manifestation of Lyme Disease?


Hello there!  I’ve been offline at home for the past week, ever since the big snowstorm that came through the northeast in late October.  The wet, heavy snow landed on trees that still had their leaves, leading to incredible amounts of damage and fallen limbs.  That night as the snow fell, we listened to branches cracking and snapping and falling and saw arcing electricity light up the sky as wires were torn down.  By morning hundreds of thousands of people were without power, including us — our wires were pulled off the side our house by falling branches.   30 foot tall trees were snapped in half, like toothpicks.  (That picture is of the end of our driveway)




On the Friday before the storm I received my order of 60 pounds of grassfed, high quality beef from Paidom Ranch in Texas.  On Sunday morning I filled 20 freezer bags full of the fresh snow and stuffed them in the powerless freezers and fridge, so the meat was still nice and frozen even after a few days without power.  Without heat and daytime temps in the mid-fifties, it might have been just fine as it was.  Halloween was put off until the following Friday night, though the neighborhood is still a mess.  Power came back in two days, but our wires were still on the ground, caught in a turf war between the utility company, local electricians, and the town inspector.  Back in Texas where I’m from, the utility company is responsible up to the meter — here there is something of a gray area between the property line and the meter, which would be okay, except you are at the mercy of the utility company as to when the power comes on and off so you can repair the lines on your property, leading to the ridiculous situation where we had live wires ready to electrocute anyone unlucky enough to trespass for several days, until the town inspector intervened and made the power company fix the problem.  

 Well.  As I write this article, we are still offline at the house with respect to cable TV, landline phone, and internet (so-called bundled services are so much fun!).  I’m hoping it will be back in the next several days so I can publish — fortunately the smartphone works for email and the like.   

But enough of our tale of first world woe, except the disease I am about to discuss has long been maligned due to the attention it has received affecting wealthy Connecticut kids.  However, I’ve seen many afflicted folks in my practice here in Massachusetts, and several family members and friends have been treated for it.  So I take Lyme Disease, or Borrelia burgdorferi very seriously.  Borrelia, along with several other nasty organisms, such as the microbes that cause babesiosis, ehrlichiosis, Rocky Mountain Spotted Fever, and rickettsia, are all spread by dirty tick bites.

(Quick and easy tic repellant for the spring and summer - 2 tbs coconut oil, 1 tbs aloe vera gel, 25 drops gardenia or rose oil, 25 drops lavender oil. The essential oils can be found at Whole Foods. Stir and smear on ankles, wrists, forehead, nape of neck, belly, and anywhere else tics are liable to climb in.  Last summer prior to use of this ointment we had 6 tics found on kids and husband (tics and mosquitos do not like me - I am too sour) - afterwards no tics whatsoever. Thanks to @OldSalt72 for the link to the recipe) 

Lyme disease is endemic to the area in which I now live, and if transmitted, can become a multisystem inflammatory disease that can affect the skin, joints, heart, and nervous system.  Borrelia burgdorferi is a spirochete gram-negative bacteria in the Treponemataceae family, like the agent that causes syphilis, rather famous for its neurological findings, Treponema palidum

Syphilis and tuberculosis are known in medicine as the “great imitators,” meaning these infections can be mistaken for many other problems, from psychiatric disorders to heart disease.  Lyme disease is very tricky as there are supposedly many false negatives when you check serology.  If you have a suspected deer tick attached for more than 24-48 hours here in Massachusetts, you are better off getting an extended antibiotic regimen just in case (for adults, doxycycline, for young kids, amoxicillin), considering the nastiness of the illness if not treated early.  

In a paper from 2002, Hajek et al screened for antibodies to Borrelia in 926 Czech psychiatric patients between 1995 and 1999.  884 healthy persons were recruited at the same time from the general healthy population.  36% of the psychiatric patients were positive in at least one antibody class for exposure to Borrelia.  Only 18% of the healthy controls were positive.  That’s a rip-roaring difference, to put it in scientific terms.  Since the psychiatric group was older, statistically, than the healthy group, age-matching was done (statistically), and the results were similar.

An older study in the US showed very low seropositivity in a group of psychiatric patients - however, the general population in the US has much less exposure to Lyme (1% as opposed to a much higher percentage of folks in Europe), and the assay used to detect the antibodies was rather old-fashioned in the older study.  (Western blot in 2002 was gold standard, ELISA a close second, and flourescent immunoassay was used in the older US study).  

The first immune response to Borrelia will be IgM antibodies, which peaks 4-6 weeks after infection, followed by the more specific IgG response, which peaks at 6 weeks, but like IgM can persist for months to years.  Antibodies circulating in immune complexes are likely to signify ongoing disease activity.  

If Borrelia burgdorfi is related to psychiatric problems, there are two main mechanisms which could be responsible.  Patients vulnerable to psychiatric disease may also be more susceptible to Lyme or neurotoxic effects due to genetic or other factors.  Second, Borrelia may cause psychiatric symptoms, which is the most parsimonious explanation.  PCR analysis and other advanced methods ought to be employed in the future, and more surveys run on the population to better clarify this phenomenon.

In short, Borrelia burgdorfi is one of those suspicious, long-term, nasty  and sneaky pathogens that could contribute to inflammation and issues in the brain for years or decades.  It may be well one of the many inflammatory activators that are increasing our psychiatric diagoses in recent times, along with diet, lack of sleep, lack of sunshine, increased stress, and lack of exercise.  The problem with Lyme is that many people who seem to have symptoms (and even those with known tic bites and classic rashes) do not test as positive.  But is it really a solution to give everyone a course of doxycycline?  This issue is my question with respect to any infection that may have neuropsychiatric symptoms - we need more data.  In the mean time, I like anti-inflammatory, nutrient rich diets and plenty of sleep, sunshine and stress reduction.

15 comments:

  1. Hey Emily!

    As a third year medical student, I love your blog.

    I have a quick question (ok, maybe not so quick)...

    Have you ever heard of Lyme disease causing dyspnea with exertion? I have a 65 year old friend that was attempting his 3rd thru-hike of the AT this past summer when he started having dyspnea on hills around the middle of Virginia. He got off the trail in May, and to this day he can't hike without running out of breath.

    The doctors can't figure it out and he is convinced it's Lyme disease. I am well aware of the neurological manifestations of Lyme, but was wondering if you had ever heard of the symptoms above.

    Thank you for the answer and for the great blog!

    Woody

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  2. The lime decease was found in the 5000 old frozen mummy in the Alps. It is piety we are not better protected from that thing after so many years of evolution.

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  3. These arguments based on correlations lend themselves to the usual remark and can be read the other way round. Does mental health-related underlying metabolic disorder / cause of inflammation increase the chance of getting the Lyme disease, Toxoplasma, Malaria, or probably even flu or virus-related cancers? If this were the case this would be a dead end. 18% positives among controls remains a huge figure to live comfortably with.

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  4. Emily, great blog first of all. I am a doctor, and one of my medical students wants to go into psychiatry, and I introduced her to your blog. I am definitely going to try that homemade insect repellant. The only think is that once Lyme's disease gets into the brain, like tertiary syphillis, it is uncurable, as I understand it. I know someone whose son has had it for years and is on chronic suppressive antibiotics as a result. I would ordinarily agree with you about the overuse of antibiotics and vaccines. I do think the are generally an industrial racket that pushes huge economies of scale. Unfortunately, this is not taken seriously when Jenny McCarthy becomes the spokesperson for the movement. Ugh. Anyway, all I'm saying is that aggressive treatment is what I would do, and I would focus more on getting a more reliable test, which seems to be the problem above all. If I had a negative test, I would certainly take antibiotics, especially if I spent a summer vaca in the woods. Anyone else disagree? Thanks. I love your blog. Super informative. Keep up the good work.

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  5. WEC - Thanks! It is my understanding that Lyme can cause many autoimmune-like symptoms - certainly one can get pleural effusions (though that is exceedingly rare) and dyspnea symptoms.

    Galina - they evolve faster than we do!

    Bolalbi - yes, fair point, I think well-addressed in the article (the full text is linked).

    Dr. Ostric - thanks! And I think with negative tests but suggestive symptoms I am all for a course of antibiotics (actually, both my daughter and my husband had a course after tic bites this spring - prior to using the tic repellant) What I don't know is what would be the point of a long course of antibiotics if there were no positive test and no other symptoms except for psychiatric ones and living in a Lyme endemic area. That seems like an exceedingly slippery slope. That is not what you are suggesting, but symptoms can be very vague, and antibiotics more caustic than we think sometimes.

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  6. 88% of Alzheimer are positive to helicobacter as against 47% controls. If we follow the same line of reasoning an y% of Alzheimer are caused by helicobacter. All these studies check for external factors as possible biases of counterfactuals. None considers likelihood of getting infected if already in a given condition. Infection is never considered as conditional to metabolic conditions broadly defined.

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  7. Emily, did you try something special in order to restore your family members gut flora? I read somewhere that gut environment still not recovers enough ofter 2 years after antibiotic use. Sometimes people don't have a choice, like when they have to be treated for the Lime decease.

    I used to take antibiotic once a year after the flue at the beginning of the year before I started LC. It was a 2 months ordeal - first flue, then bronchitis, then the worsening of my asthma that required 3 weeks of the regular inhaler use . Last 2 years it is not the issue any more . I didn't fill the asthma prescription since I started LC.

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  8. Dr. Deans, I do think that the modern medical system rewards and incentivizes technicians rather than clinicians, which has made modern medicine more akin industrial process to provide technology and procedures and medicines. I think that is why people get meds they probably don't need. Also fear plays a big role. CYA, as you know. These are a powerful double whammy that keep doctors from thinking critically. Your point about Lyme's disease is well taken, and I am very glad you value your role as a clinician and teacher(that's the root of doctor anyway) by providing an interesting and informative and thoughtful blog.

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  9. Reminds me of something I read about Cat Scratch disease: "for some people chronic infection can be as debilitating and hard to diagnose as Lyme disease"
    http://veterinarynews.dvm360.com/dvm/ArticleStandard/Article/detail/698412

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  10. Bolalbi - there are plausible mechanisms by which Borrelia could cause psychiatric symptoms, and, as the authors note, that direction of causality is by no means proven, but is the most parsimonious explanation. Certainly homeless people could be more at risk for many tic bites, but there weren't homeless people in the study. In Alzheimer's I'm certain there is gut dysfunction as part of the pathology, thus a plausible mechanism for Alzheimer's making one more susceptible to H pylori. Again, no causal arrow, but we're just speculating here.

    Galina: No, not really, just yogurt! As much as I keep seeing notes of "guts are never the same" I've read many an account of mouse flora being completely massacred by multiple courses of antibiotics no humans would undergo, only to have the flora essentially rebound in a couple of weeks.

    Dr. Ostric - the CYA issue is huge! Agreed

    Kathy - there are lots of sneaky bugs out there!

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  11. I recently moved from Connecticut to Florida, and I've noticed that my new neighbors seem to be more relaxed, laid back (back-lain?), and all in all less bat-shit crazy than my friends in CT. I thought it was cultural issues, but maybe it's just cause there's less Lyme disease here where the weather suits my clothes?

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  12. There are some interesting papers on the role of microbes in autoimmune diseases and their role in down-regulating the immune system, for example:

    Immunostimulation in the era of the metagenome, Cellular & molecular immunology, 2011.
    http://mpkb.org/home/publications

    As I understand it, some of the things they cover are:

    1) vitamin D governs the expression of many genes involved in the immune system
    2) various bacteria target the immune system by interfering with the role of vitamin D
    3) as the immune response become less effective other bacteria gain a toe-hold and further weaken the system
    4) treating inflammation with immune suppressors makes the patient feel better but further down regulates the immune system
    5) some antibiotic treatments that interfere with the cell wall of bacteria aren't effective where the immune system is already compromised resulting in L-forms of the bacteria which are much harder to detect. As I understand it Lyme is one of these.

    To someone without a medical background it sounds like a plausible theory.

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  13. Could the sequence of causes be
    1. Lyme infection
    2. Inflammatory response
    3. Increased intestinal permeability
    4. food allergies, autoimmune and psychiatric disease

    Why would be so many people reporting gluten allergy in the "Lyme" thread of the celiac.com forum?

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  14. Ian Lipkin is doing a very interesting study into possible pathogen involvement in ME/CFS. What he is using is called "Next Generation Sequencing", some sort of "deep" sequencing, which should turn up any pathogens by finding their gene-sequences. That kind of study is something that would be helpful to do for other conditions like the psychiatric diseases you write about – but should be used for all diseases with unknown cause.

    If this deep sequencing works (and gets cheaper), then we have two high throughput tools to look for disease causes with "fishing expeditions":
    - Human Genome Sequencing to look for genetic causes
    - Next Generation Sequencing to look for pathogens

    Now we need better mass spectrometry to look for involved substances.

    Of course the risk is that the medical science runs amok like with the cholesterol train-wreck when it finds a correlation but doesn't bother to check for causation…

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  15. Thanks for sharing with all of us .

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