SAFETY
Before we get to the science and strategies, know that the vagus is all about safety. You may be thinking, “I feel safe.”  We don't face animal predators or an enemy tribe, like your ancestors, but we still experience threat.  It may be a family conflict, a toxic workplace, the evening news, a political facebook post, a honking driver or the tone of someone’s voice. The threat may be recalling what we said or didn’t say, or imagining we'll lose our train of thought in a presentation. It may be the endless chatter of what we have to do. If we experienced early life adversity or abuse, the threat may be a type of person or even people in general. It may be a smell or a sound related to an event we don't consciously remember.  For those with complex chronic illness, random, frightening and confusing symptoms can lead some of us to experience our own body as the threat.  

Other threats our body perceives, that our thinking brain may not, are microbes (candida, mold, virus including COVID 19, lyme, etc) and/or toxins from microbes.  There are also the toxins we can accumulate from the outside (such as metal, chemical, and mold toxins) or a soup of all of our toxic exposures.  We come into the world with a level of toxicity and we have a threshold that when reached alarms our body. How quickly this happens, if at all, depends on the amount of exposure and how robust our inherent ability to detoxify is.

We can and should simplify our activities, relationships, items and exposures to those that support our wellbeing.  In these times, we can and should bolster our ability to detoxify.  Still, modern life will be more stressful and toxic than our bodies were designed for. Our stress response was meant for infrequent threats, not daily living. The consequences of this chronic stress include a cascade of stress hormones, inflammation (the immune system's responses to threat) and the expression of certain genes, all of which lead to disease.

INADEQUATE OR DISRUPTED ATTACHMENT & EMOTIONAL TRAUMA & TOXICITY
Neurological pathways of chronic stress can be laid down during early childhood or even later in life through trauma, repeated trauma, repeatedly recalling a traumatic event or even chronic health issues. It is well known that those with early childhood adversity are more at risk of disease later in life. This is likely because of overly developed neurologic wiring for survival.  Even when out of harm's way the body doesn't feel safe.  Similarly, people with high levels of toxicity often don't feel safe, even if they don't know why.  
 
This type of trauma and/or toxicity can lead to sensitization - a phenomenon in which the stress centers in the midbrain (not the thinking cortex) are essentially staying on and reducing the functioning of the vagus nerve.  Likely most of us with complex chronic illness or psychiatric conditions were born "wired for danger," due to a mutation in a gene involved in stress hormone pathways as is argued by Dr. Sharon Meglathery's RCCX theory.  But, just as our collection of genes isn't our destiny, neither is our wiring. 

NEUROPLASTICITY
Our nervous system is more malleable than we might think. With the help of the vagus nerve, we can repeatedly give our body and brain the experience of feeling safe. The magic of neuroplasticity is that we are constantly forming new neural pathways and the more we have an experience, the more new pathways are reinforced. If we're chronically thinking and talking about our problems or our symptoms, we're further reinforcing pathways of defense. I can assure you, I have done plenty of this myself. My friends and family would agree. Instead, we can choose to chronically think about what we’re grateful for (even when it’s not easy) and we can chronically help our body feel safe (with the tools I’ll get to below). 

THE BRAKE
Think of the vagus as the brake we can use when we need to decrease our physiologic reaction to stress. And know that we can fine tune that brake and have it working so well that it starts to mitigate our body’s response - even before we realize we’re under stress. It allows us to become exceedingly resilient and able to bounce back to a calm state quickly. If that weren’t enough, an ability to self regulate allows us (without conscious intent) to bring calm to those around us. 

SOCIAL COMMUNICATION
We receive input about the safety of others and our environment through our eyes and ears. Without conscious thought, this information is carried in part and influenced by the vagus. The vagus sends information to our organ systems as well as the muscles of our head and neck.

Many individuals with autism are dealing with high levels of toxicity in their body, as are most people with brain related symptoms. Toxicity is a constant “threat.” When we’re in danger, our body mobilizes to defend us, not to prepare us to hang out with friends. Those with autism often have severe sensory issues (to loud noises, bright lights, etc) as well as severe deficits in social communication as evidenced by lack of eye contact, the way they speak and even the way they hold their head. These sensory issues and deficits in social communication are all influenced by cranial nerves which are influenced by the vagus nerve. If you’ve ever had depression or even the flu, it may have been hard to look at or listen to others. “Get out of my face,” may have been what your body was communicating. This particular physiological stress response involves immobilization - a shutting down or withdrawing, as opposed to the well known flight or fight response.

ANCIENT UNDERSTANDING
There’s evidence that ancient cultures not only recognized the importance of the vagus nerve, they revered it. Anatomically, this large nerve would have been hard to miss. It’s the longest cranial nerve in the body, going from the lower part of the brain, down the neck all the way down into the abdomen with many offshoots along the way. Vagus means wandering in Latin. Ancient rituals which have carried into contemporary religious and/or spiritual practices such as chanting, praying, meditation, dance and posture shifts such as kneeling and falling prostrate would have exercised vagal pathways and resulted in a calm and compassionate mindset.

While our ancient ancestors were embodied, we tend to be “in our heads” analyzing, reasoning, calculating and judging. For many of us, our body is something to make look better, work better, or to get us what our ego wants. We outsource experiences like singing and dancing to a very few. Thoughts of these or even of meditating can trigger a stress response. Growing research (which our ancestors would laugh at, but of course we need) into the impact of meditation, yoga, singing, dance and breathing practices are proving that when it comes to lowering the stress response and thus healing from disease, the body and not the mind is where it’s at.

CALM, CONNECTION, COMPASSION & CONTAGION
Only when we feel safe and trust that we’re okay (which in these times takes practice) are we able to grow and repair physiologically, to tap into our higher/greater selves, create, engage with others and feel compassion. When our bodies perceive a threat, our physiology goes to survival - fight of flight (anger or panic) or shutting us down as described above. Such states are not conducive to connecting with others nor to recognizing their needs or suffering. Many of those who are insensitive to the experiences of others, live in a chronic survival mode.

Whether we intend it or not, our sense of threat or our sense of safety is conveyed by our facial expression and the tone of our voice. Depending on how self aware those around us are, they may take their own unconscious physiologic stress response onto their next encounter. Or, they may take what their body is telling them all the way up to the reasoning part of the brain, observe what is happening, and stop the contagion. We all have the choice to self observe, set emotional boundaries and know that we don’t have to take on threats of those around us (unless of course the house is on fire).

First some DEFINITIONS (simplified) to put the vagus in perspective:

Central Nervous System:

• Brain
  • ​​Cerebrum -  where we think and learn. Also involved in emotions, planned muscle movements, and our senses.
  • Brainstem - bottom of the brain, connects cerebrum to spinal cord and controls fundamental body functions such as breathing, eye movements, blood pressure, heartbeat, and swallowing.
  • Cerebellum -  controls balance, coordination and fine muscle control 
• Spinal cord - sends messages between the brain and the rest of the body (in both directions).

There's a lot going on below the thinking part of our brain that's impacting our emotions and how safe and secure we feel in the world.

Autonomic Nervous System - controls automatic functions that happen beyond the brain’s conscious awareness. Starts in the brainstem and spinal cord.  There are 3 parts:

• Sympathetic Nervous System -  Activated when we’re under threat to prepare our bodies for FIGHT (anger) or FLIGHT (“get me out of here”) by moving blood to the heart and muscles (to help us move fast) and away from the digestive tract.
  • Constriction of blood vessels to needed areas
  • ​Increase in heart rate (“my heart was about to jump out of my chest”)
  • Decreased blood flow to the gut (“butterflies in my stomach”)
  • Decreased intestinal activity ("knot in my stomach")
  • Increased respiratory rate (“can’t catch my breath”)
  • Dilation of bronchioles - so more oxygen can be taken to needed muscles
  • Immune system activation (aka inflammation) - so you can survive the potential trauma or infection.

• Parasympathetic Nervous System- The BRAKE on the sympathetic nervous system that allows us to REST and DIGEST. The VAGUS is the main component.
  • Dilate blood vessels
  • ​Decrease heart rate
  • Increased blood flow to the gut
  • Increased gastrointestinal activity 
  • Decreased respiratory rate

In this parasympathetic state, the body is able to repair itself and grow, but also to feel calm, socially engage, feel compassion and create.

• The Enteric Nervous System - “Second brain”
  • a mesh-like system of neurons that connects to the sympathetic and parasympathetic nervous systems (and is how they these systems influence the GI/gastrointestinal tract)
  • appears to be the way digestive organs communicate to coordinate digestion
  • produces more than 30 neurotransmitters
  • ​the way the microbiome (the trillions of microbes in the gut) communicates with the brain through the vagus nerve and through hormones and peptides it releases into the blood which cross the blood brain barrier.  Together these influence when we feel full, our appetite, mood and inflammatory response.

And now you generally understand what is meant by the ….

• “Gut-Brain Axis/Connection” -
  • ​the BIDIRECTIONAL communication between the brain and GI tract (connects emotional and cognitive areas of brain with gut functions).
  • involves:
    • Enteric nervous system
    • Sympathetic nervous system
    • Parasympathetic (via the vagus nerve) nervous system
    • Hormones
    • Immune cells including mast cells
    • Microbiome

VAGUS NERVE - Finally!
The main component of the parasympathetic nervous system.

• Cranial nerve 10 (There are 12. The others are responsible for much of the sensory and motor functions of our head and neck)
• Actually a pair of nerves that emerge from the left and right side of the lower half of the brain stem before wandering down the neck and into the chest
• Carries output (ie. information to other parts of the body)
• Carries input (brings information about the state of the organs back to the brain)
• Supplies motor parasympathetic fibers via branches to all the organs except the adrenal glands, from the neck down to part of the large intestine. 
• POLYVAGAL THEORY by Dr. Stephen Porges emphasizes that there are actually 2 separate nerves/branches coming from 2 separate areas of the brain that fuse together to become the vagus. The DORSAL aspect relates to the shut down/freeze/immobilization response (again, a third defense mechanism that is different from fight or flight)…..and the ventral aspect which is especially important in social communication.

Dorsal Vagus

• Over activated when we face overwhelming stress where fighting or fleeing aren’t options. Instead our body conserves resources (blood flow) and immobilizes, freezes or shuts down. Imagine the animal that feigns death (reflexively) when they are about to be killed by a larger animal (seeking fresh meat).
• Extreme danger, traumatic events - real, imagined or remembered - can cause this dorsal vagal response or shut down. (I would argue that significant toxicity can contribute to this as well)
• Physical responses include:
  • ​nausea and sweating
  • loss of bladder and anal-sphincter control
  • ​slow shallow breathing
  • Postural Orthostatic Tachycardia Syndrome (POTS) which involves lightheadedness, fainting, and rapid heart rate triggered by standing up after laying down. 
• Psychiatric symptoms:
  • dissociation - becoming disconnected from your current environment
  • depersonalization or derealization - feeling outside of oneself or feeling the environment isn’t real.
  • depressive-like behaviors (seemingly a more chronic dorsal state of immobilization) - loss of appetite, decreased energy, apathy, social withdrawal, helplessness, hopelessness, and problems concentrating.

Ventral Vagus

• A newer circuit that is also called the myelinated vagus
• Related to feeling safe and supports the ability to socially engage, create, feel compassion

THE MANY ROLES OF THE VAGUS NERVE:

• PEACEMAKER
  • Releases the neurotransmitter acetylcholine which counteracts the effects of adrenaline from the sympathetic or fight or flight response and tells our body to relax

• OVERSEER of Bodily Functions
  • Digestion -
    • ​carries bidirectional communication between the brain and GI tract
    • responsible for all things digestive from the end of the esophagus to part of the colon
    • controls involuntary muscles in the esophagus, stomach, gallbladder, pancreas, and small intestine, stimulating peristalsis (movement) and gastrointestinal secretions
    • salivation - needed for breakdown and taste of food
    • swallowing (by influence on one of the other cranial nerves)
    • also involved in the gag reflex
    • production of stomach acid which is needed for digestion of food and to prevent the overgrowth of certain microbes like candida
    • gastrointestinal peristalsis/motility - from stomach to large intestine keeping us from getting constipated
    • also involved in vomiting
    • gastric emptying
    • gallbladder and pancreatic functioning - we need bile secreted from gallbladder and digestive enzymes secreted from the pancreas to help us break down fats, proteins, and carbohydrates
    • decreases intestinal permeability and thus our vulnerability to “leaky gut” and all of its consequences including immune responses to food particles that make their way through the gut lining and into the bloodstream
    • controls blood sugar by way of fibers that inhibits liver gluconeogenesis (the generation of glucose from molecules that aren’t sugar) and thereby keeps our blood sugar from becoming elevated (which can have a number of consequences, including feeding microbes such as yeast and mold)
    • impacts the microbiome by its impact on the ph (beyond the stomach)
    • impact on gut immune function (more on this below)
    • As you can see, if sphincters aren’t working properly, ph is altered, food isn’t well digested, blood sugar is high, the microbiome is out of sorts and the bowels aren’t moving well, then problems like SIBO, candida, leaky gut, food sensitivities, Irritable Bowel Syndrome and/or Inflammatory Bowel disease become more likely
  • Cardiovascular
    • the right vagus is more likely to carry fibers that supply nerves to the heart
    • regulates heart rate - activation leads to decreased heart rate
    • regulates blood pressure and the constriction and dilation of blood vessels
    • excessive activation (likely through the dorsal aspect of the vagus) could cause a sudden drop in cardiac output and secondary decrease in blood to the brain (as may be seen with fainting)
  • Respiratory
    • keeps the larynx open for breathing
    • decreases respiratory rate
    • constricts bronchi
    • regulates coughing & sneezing
  • Sweating

• ACTIVIST against inflammation
  • Influences our immune response - preventing inflammation throughout the body
  • Counteracts the fight or flight response which is inflammatory
  • Prevents the increase in the production of cytokines/inflammatory mediators by mast cells that influence various parts of the body including the brain. While there are ways to stabilize mast cells, accessing the vagus nerve is extremely important.
  • Increasing vagal tone will inhibit cytokine production.

• FILTER of sensory input
  • Despite all that influence on our organs and even the motor nerves of the head (which I’ll get to), 80-90% of the nerve fibers in the vagus are sensory meaning they bring information from the organs and even other cranial nerves (of the head and neck) and take that information to areas of the lower (not thinking part) of the brain
  • Tells us if our stomach is full (another way it can influence our weight)
  • ​​Tells us what’s going on with the microbiome in the GI tract
  • Sensory information from our eyes, ears (including inner ear which is important for balance), mouth and nose. This is because of its connection to other cranial nerves.
    • Nociception - relates to how neural pathways of the autonomic nervous system evaluates information from our senses about our environment and the state of our body to determine if a situation is safe or dangerous. This is what is meant by "listening to your body. "  You might also call this intuition or your "sixth sense" - a knowing that exists outside the thinking part of our brain.
      • Example -  We feel safe in our bodies when we are with people with warm expressive faces and a calm tone and appropriate tone and fluctuations in their voice.  Our eyes and ears (by way of the vagus), are better at picking up on a fake smile (by the person’s eyes) or an incongruent tone of voice than the reasoning part of your brain which is looking at the mouth and listening to the words. 
  • Sensory Issues - Impairment in vagal nerve functioning can also be at play for those with “sensory issues,” seemingly because of how the vagus influences the incoming information from those nerves.
    • Hearing (cranial nerve for hearing) - ie. can’t tolerate loud sounds, difficulty processing what someone is saying (especially when there are other noises)
    • Balance (cranial nerve for inner ear) - ie. problems with balance and vertigo.
      • There is evidence that vagal circuitry is interconnected with the vestibular system, (and why non-invasive vagus nerve stimulation, discussed later alleviates vertigo in vestibular migraines)
    • Vision (cranial nerve for the retina) - sensitivity to bright lights
    • Smell (cranial nerve for the olfactory nerve)- especially bothered by certain smells
    • Taste (another cranial nerve involved in taste)
• INFLUENCER of social communication
  • By way of its strong influence on other cranial nerves that control muscles of the neck, throat, ”voice box,” mouth, eyes and ears.
    • Speech
    • ​​Laughing
    • Singing
    • Ability to visually track (as in reading) and easily make eye contact

CAUSES OF AUTONOMIC DYSFUNCTION/LOW VAGAL TONE:

• Emotional - Anything that leads you to be in a chronic state of emotional stress
  • attachment disruption or insecure attachment
    • much of our wiring is laid down during our first 3 years of life. What we may not “explicitly” remember, our bodies can “implicitly” remember.
  • early childhood adversity
  • emotional trauma
  • chronic stress
• Physiologic - Anything that leads to a chronic state of physiological stress
  • infections or microbial overgrowths - bacteria, virus, yeast, mold, abscess (ie. tooth abscess), etc.
  • toxicity such as mold toxicity (or other biotoxins)
• Structural
  • ​​Damage to the nerve itself
    • damage from toxins
    • from alcohol or diabetes
    • from surgery or other trauma
  • Issues involving neck and/or skull
    • upper cervical instability (the bones of the neck moving more than they should) which can impact the natural curve of the neck causing the vagus to be stretched which can disrupt nerve signaling. This can be due to:
      • Injury (obvious whiplash or less obvious repeated trauma from tumbling or contact sports) 
      • Joint laxity for those joint hypermobility as in Elhers Danlos or in those are especially flexible 
    • ​​​scar tissue impinging on the vagus or adhesions (scaring down) of the vagus nerve from a previous injury
    • decreased cranial compliance due to injury (we should have a degree of give to the joints of our skull)
  • Mouth
    • tooth extraction or braces - can cause a chronic sympathetic stimulation or dorsal vagal state (Rosenberg)
    • misalignment of the jaw
    • tongue tie - which reduces the overall movement of the tongue resulting in low vagal nerve stimulation. This can look like fight of flight due to lack of stimulation of the the cranial nerve that supplies the muscles to the tongue.
    • mouth breathing - again results in low vagal nerve stimulation. When we correctly breathe through our nose, our tongue is on the roof of our mouth. This and correct swallowing stimulates nerves of our tongue and the vagus.
• ​Combination of any of the above

SYMPTOMS THAT CAN POINT TO VAGAL NERVE DYSFUNCTION

• Cranial nerve dysfunction (the vagus itself or symptoms related to those cranial nerves that the vagus can influence)
  • Uvula (tissue hanging down in the back of the mouth) not staying centered when you say “ah.” The palate should elevate symmetrically.
  • Lack of gag reflex
  • Hoarseness
  • Problems swallowing
  • Aspiration (unintentionally getting food or liquid into windpipe)
  • Ringing in ears/tinnitus - if vagus nerve is impacting the cochlear nerve.
  • Vertigo - can be measured by having someone stand with eyes closed and seeing if they sway.
  • Clenching of teeth/TMJ - has been linked to high sympathetic tone (and thus lack of the parasympathetic brake)
  • Problems with social communication - difficulty using your neck, eyes, hearing and speech to connect with another person. Deficits here could look like turning away, lack of eye contact, absence of speech or mechanical sounding speech.
  • Sensory processing issues likely as well (sensitivity to bright light, loud sounds, certain odors) (See link below)
• Muscle tone
  • too hard (sympathetic) or too soft (dorsal vagal circuit is activated), just right (ventral vagal). An example of a high sympathetic tone in a child may be toe walking.
  • Handshake - too tight (sympathetic), too limp, damp or cold (dorsal) Rosenberg
• Gastrointestinal Symptoms
  • ​constipation, bloating, SIBO, candida, leaky gut, food sensitivities, Irritable Bowel Syndrome and/or Inflammatory Bowel disease.
• Cardiovascular
  • ​Low blood pressure (heart rate too low) or too high
  • Postural Orthostatic Tachycardia Syndrome - as described above
• Chronic inflammation
  • in the form of mast cell activation, systemic inflammation and autoimmune conditions
• Psychiatric symptoms
  • ​​​Anxiety, panic, depression, dissociation, depersonalization and derealization

ASSESSING VAGAL TONE
When we feel safe and our autonomic nervous system is working optimally, there is a slight activation of our sympathetic nervous system on inhalation which causes our heart to beat a little faster. When we exhale, the parasympathetic nervous system causes our heart rate to decrease. The difference in these two heart rates is referred to as heart rate variability.

Heart Rate Variability:

• how vagal tone is measured
• high heart rate variability = high vagal tone
• ​considered a measure of
  • how well we are balancing our emotional lives.
  • flexibility of our heart and nervous system (which reflects our health and fitness)
• low heart rate variability (which can be improved upon) is - 
  • associated with a number of medical conditions
  • a predictor of future health problems including obesity, high blood pressure, heart disease.  There is evidence that it can predict cancer, cancer metastasis and the mortality of people with cancer.
  • decreases with age

There are devices available to measure heart rate variability, including chest straps. I use an earlobe sensor along with the Inner Balance App from Heart Math.

IMPROVING THE TONE OF THE VAGUS NERVE
aka - accessing the vagus nerve or “balancing the autonomic nervous system"
When you increase vagal tone, you are activating the parasympathetic nervous system. The more you do this, as with anything, the more easily you can do it without great effort. This means relaxing faster when under stress and optimizing all of those systems already mentioned. As you can see, this is bidirectional - high vagal tone leads to improved physical and mental health and better physical and mental leads to better vagal tone.

• Passive - don’t require conscious awareness
  • ​Put your body in a safe space - as one might do when meditating, praying or other contemplative practices. This means removing yourself from things, people and spaces that can lead to stressful thoughts which stimulate your sympathetic nervous system.  You want instead to exercise your parasympathetic nervous system/vagus nerve.
  • Meditation is one example. Because your eyes are closed, you don't have reminders, for example, of 'that thing you need to do'.   If sitting quietly and not having stressful thoughts sounds stressful,  consider guided meditations which help shift your attention in ways that calm the body and allow you to experience optimal emotions.  My own preference currently are the morning and evening meditations by Dr. Joe Dispenza.  
  • Be with safe people with whom you have positive social interactions. This improves vagal tone (and improves mood) in a number of ways
    • All neural pathways of social engagement are being used - your neck, mouth, face, middle ear, voice-box and throat.
    • When you turn or lift your head to look at someone (accessory nerve), look into their eyes (optic nerve) listen to them (cochlear nerve) and then speak back or (vagus nerve) while modulation of your voice (again cochlear nerve) or better yet, laugh (vagus) and make facial expressions and eye contact (oculomotor), you are accessing the vagus and many of the nerves it influences. Collectively, this down regulates sympathetic pathways.
    • Safety is key here - if you feel threatened by that person, your sympathetic nervous system will predominate - if not outwardly with anger or fleeing, then inwardly through the physiological stress response
    • Social distancing due to COVID is likely having significant effects on our collective mental and physical health for these reasons (unless it's allowing those of us who don't live alone to be more present with those with live with). It is unknown how videoconferencing (Zoom) compares to face to face in these regards. While an intention to connect, the act of looking at a trusting person’s face, hearing their voice, talking to them and making facial expressions will all be impactful, there are likely subtleties and even unseen energy that is missing in these types of interactions.
• ​Active - conscious behaviors that trigger specific neural mechanism that in turn, change one’s physiologic state
  • Simple deep breathing
    • Breathe deeply from diaphragm so that stomach expands out. This lowers the diaphragm which pushes downward and influences the vagal outflow of the heart. Exhale slowly
    • 3 deep breaths can interrupt the fight or flight response​
  • ​​​Singing or Chanting or Humming
    • Like breathing exercises, singing requires extended exhalation relative to inhalation.  But here, you're also monitoring sounds. The vagus is connected to the muscles at the back of the throat and vocal cords. You may have seen Kodi Lee, a young man who is blind and has autism, on American Idol. When he is singing with his beautiful voice, you would not know he has autism, however when he's not, his social communication issues are more evident.  Similarly stuttering or tic like behaviors can cease when someone is singing.
    • Humming and gargling can also access the vagus
  • ​Postural shifts
    • Dance or other movement
      • If this sounds daunting, start with turning on some music at your desk. Even if you have low energy or even pain, there are ways to start to move to music.
      • ​​There is a TED talk by Frederico Bitti who had a movement disorder called cervical dystonia.  He discovered that when he danced, his symptoms remitted. This became his therapy. (His talk includes video of him with his symptoms and without while dancing).
    • Yoga - which also incorporates attention to breathing 
    • Contemplative practices which involve postural changes, such as kneeling, seem to access vagal tone (and thus down regulate defense) by way of baroreceptors (in arteries which pick up on pressure changes created by postural changes). What we’ve assumed is a show of reverence for a higher power, may have been, at least in part, a means to physiologically access another state of mind (and body).
  • ​Cold treatment 
    • Exposing yourself to cold on a regular basis to increase parasympathetic activity
    • This might look like:
      • ​finishing showers with cold water
      • putting face into ice cold water
      • stepping outside momentarily into the cold

While cold treatment isn't how I like to access calm, dancing, singing and meditation are.  For years, I longed to sing and dance.  While my body knew what it needed, my under-methylated mind couldn't justify spending time on such activities. This past year, I committed to make these part of my life. I awkwardly started dancing each morning to exercise videos.  My movements became more awkward each time my husband or daughter walked through the living room.  But, I persisted. Aside from accessing the vagus, I was gradually rewiring a part of my brain that had been dormant since childhood.  Now I find myself happily dancing without thinking and at unexpected times through the day.  My daily practices also include a morning and evening meditation.  It's an especially good day, when I remember to sing.

• Tools one can do on their own or with assistance
  • Stanley Rosenberg’s book  - Accessing the Power of the Vagus Nerve: Self-Help Exercises for Anxiety, Depression, Trauma, and Autism - has exercises involving the cranial nerves that take about 10 minutes a day.
  • Massage
    Can stimulate the vagus nerve and increase vagal tone. Foot massage, specifically has been shown to increase vagal tone and increase heart rate variability and decrease the fight or flight sympathetic response.
  • Tapping / EFT /Emotional Freedom Technique - tapping on particular parts of the face and upper body while cognitively identifying the thought that is creating the stress response, recognizing the feeling in the body and essentially changing the narrative - changing the story that you are telling yourself. This is much easier when our bodies are calm which is what tapping and other interventions do.
  ​Others that require professional involvement
  • Frequency Specific Microcurrent (FSM).  FSM has the potential to access the vagus nerve directly.  It has also been used to address structural issues impacting the vagus such as adhesions and many downstream effects of vagal nerve dysfunction.
  • Surgically implanted devices approved by the FDA that periodically stimulate the vagus nerve. There are also non invasive vagal nerve stimulators.  (Though I am trained in the use of FSM, I don't have experience with vagal nerve stimulators).  They have been used and/or are being studied in refractory epilepsy, depression, PTSD, inflammatory bowel disease, Rheumatoid arthritis, cluster and migraines, obesity, Bipolar Disorder and Alzheimers. They have been shown to cause weight loss in those with epilepsy or depression.  Accessing the vagus nerve in other ways would be expected to have similar effects.
  • Addressing structural issues affecting the vagus such as cervical instability, tongue tie, etc. with appropriate specialists.
  ​Healthy Gut Bacteria
  • Because of the bidirectional nature of the vagus nerve, a healthy microbiome is key. While there’s growing evidence that gut bacteria improves mood and lowers anxiety by affecting the activity of the vagus, you’ve probably done your own research. When you’re eating sugar and carbs, you likely feel more stressed and irritable.  When you’re "eating clean," you're likely more calm and and more patient with those around you. This is likely due to problematic microbes thriving on sugar and carbs. The more there are, the more toxins our body is perceiving as a threat and the more our sympathetic system is working and our parasympathetic is not.

STILL WANT TO USE YOUR BRAIN?
If after all of the above, you still insist on using your thinking brain, then use it to make a habit of sitting yourself down in a quiet space and exercising your vagus nerve. Your ability to access calm is always with you.  Practice and you will become less reactive physically and emotionally and when you do become stressed, you'll recover and return to balance more quickly. This takes time.

You can also use your brain to notice your physiologic state throughout the day. Is your body telling you to fight, or flee or did it just cause you to check out? Does it feel calm and safe? Did your neck just become tight? Do you feel like your heart rate picked up? Are you holding your breath or breathing faster?  Such awareness takes practice, especially in our disembodied culture.

When you do notice, THEN go to your brain and wonder, “What is my body trying to tell me?"  "Is there something I need to pay attention to or do something about or not?"  After noticing, then go back to your body, specifically to your autonomic nervous system - the vagus, and ask it to help you get back into equilibrium.

PRACTICE BEING YOUR OWN NURTURING CAREGIVER
A secure attachment with a “good enough” responsive caregiver in our early life is what allows us to have good emotional and physiologic regulation (even if this regulation is derailed by other events and exposures). The same holds true with our connection to our body.  A consistent tending to our need for safety is essential for healing and maintaining wellbeing.  If you’ve lived in a chronic state of stress, it takes practice to learn to self regulate and feel safe again or for the first time.  If you struggle with chronic complex illness or a psychiatric condition, you could do everything perfectly (whatever that means to you) as far as diet, supplements, removing toxicity and sources of inflammation, and if you haven’t learned to access the vagus nerve, you may still struggle to heal and thrive.  

I hope I've given you reason to become that nurturing caregiver - the kind who repeatedly reminds your body that you are safe.  And, too, I hope I've given you a good reason to sing and dance.  

By Courtney Snyder, MD

This post goes out to those who are unknowingly deep in the throes of mast cell activation and/or brain inflammation.  

Though our culture is only starting to consider psychiatric conditions as inflammation of the brain, if you or someone you know has panic attacks, depression, mood swings, ADHD, brain fog, chronic fatigue, PTSD, autism, cognitive issues or even dementia, then you know the destruction neuroinflammation plays in people’s lives.  ​

Understanding brain inflammation can make the difference in the stories we tell ourselves about ourselves.  It can make a difference between feeling shame or feeling we’re having any other symptom like an inflamed joint or a rash.  It can make the difference between years of suffering and getting help or making needed lifestyle changes. This awareness can even make the difference between whether someone chooses to live or die. For physicians, therapists and other practitioners in can impact how they interact and treat their patients. 

Tweaking neurotransmitter functioning, the primary role of modern conventional psychiatry, isn’t the same as treating inflammation in the brain.  While psychotropic medications may help lessen symptoms (and can be life saving), they don’t address root causes including inflammation. In those with high immune reactivity, they may even trigger an inflammatory response themselves. 

In this post, I’ll do my best to lay out the science as well as speak to the personal experience of brain inflammation. Because this topic requires explanation, I’ve tried to make it easy to jump ahead to find areas of interest. First some definitions:

Inflammation is a good thing. It’s a protective response to injury or infection. It helps remove the problem (toxin, infection) and start tissue healing.  

Neuroinflammation is when the central nervous system (the brain and spinal cord)  is involved.

Neuroimmunology - the study of this interface between the immune system and the central nervous system.

Neuroimmunoendocrinology - the study of the interface between the immune, central nervous and endocrine (hormonal) systems. These systems can influence each other in many directions, but for now, know that we have a stress hormone from the brain that activates the immune system to act on the brain (and the body). 

Psychoneuroimmunoendocrinology - the study of how psychological and emotional stress can cause this hormone (and others) to be released from the brain to activate the immune system to inflame the brain (and body).  When you hear, “stress causes inflammation” - that’s what they’re talking about. 

What’s Happening at a Cellular Level?
Meet what I think are the three most important players when it comes to brain inflammation and thus psychiatric conditions.  Later I’ll explain how they work together to cause symptoms, and how we can calm them down so we can heal and eventually thrive.

1 - Mast Cells

• part of the immune system - mediate immune, allergic and inflammatory response 
• everywhere in the body, but especially concentrated in areas in direct contact with the outside (skin, respiratory, digestive and urinary tract)
• sensors - they sense what is going on in the tissues
• first responders when the body perceives a threat (toxins, infection, etc) 
• they act fast (resulting symptoms occur quickly after a trigger) 
• great communicators - they have granules/ bags with many inflammatory mediators that when released do lot of helpful and potentially destructive things 
• those mediators communicate with a lot of other cells and tissues which is why they can cause so many seemingly unrelated symptoms throughout the body and brain
• can be triggered to release those mediators by toxins, unwelcome microbes, chemicals, heat, cold and emotional stressors, among other things
• can be triggered by CRH (see below) - a stress hormone from the brain

2 - Microglial Cells 

• also part of the immune system, but in the brain  
• job - remove damaged neurons, waste and things that aren’t supposed to be there and to keep the brain healthy
• activated by mast cells 
• can be activated by CRH (stress hormone from the brain described next)
• too much activation means too much cleaning up (excessively scrubbing any part of your body leads to inflammation and tissue destruction- in this case brain cells/tissue)

3 - CRH Corticotropin Releasing Hormone (or Factor) 

• a hormone released from part of the brain when we are under stress (physiologic or emotional)
• it’s also released from mast cells 
• there are receptors for CRH on mast cells and on microglial cells - when it hits those receptor it activates those cells to do their thing which is to create inflammation
• This helps explain how emotional stress causes “inflammation” and why lowering inflammation in the body and brain requires lowering stress in our lives and our stress response (and why I’m glad I’m a psychiatrist). In short, supplements, medication and dietary changes alone are not enough.
  • There is a theory, called RCCX theory that suggests that about 15-20% of us have a mutation in  an enzyme in our stress hormone pathways that results in us having more CRH released when our body (or brain) is under stress. This means we have more mast cell and microglial activation leading to more inflammation.  It also means we will be more prone to brain related symptoms and certain health issues and need to be more intentional about lowering our stress response, as well as avoiding toxins and keeping our microbiome healthy.

These three players are essential.  All is good until the burden or threat is greater than our ability to manage it.  Examples would be if there is:

• ​a lot of toxicity (chemical, metal, or from mold, yeast or other microbes),
• unwelcome microbes that aren’t easily removed (lyme, a virus, mold, yeast overgrowth) or
• if we are chronically stressed, have a traumatic event, or have the dysregulated stress response that comes with inadequate or disrupted early attachment or and more often...
• a combination of any of these.

These “stresses” call for more cortisol and to get more cortisol, the brain releases more CRH/ Corticotropin Releasing Hormone, which tells the adrenal glands to make more cortisol.  This increased CRH (which again binds mast cells and microglial cells) leads to more mast cells being activated - dumping their mediators which activate more microglial cells (in the brain) resulting in brain inflammation and disrupted neuronal connections. Chronic inflammation can lead to cell and tissue death which is what we call neurodegeneration. The most common example is dementia.  

GENETICS
While there is certainly evidence that there is a genetic vulnerability to mast cells becoming overly active, I and others would argue that toxicity (especially mold toxicity) tends to take it to another level. 

ASSOCIATED DIAGNOSES
Mast cell activation occurs in asthma, allergy, arthritis, cardiovascular disease, interstitial cystitis, psoriasis, atopic dermatitis, cancers and metastasis, endometriosis, obesity, ulcers, prostatitis, periodontitis, irritable bowel syndrome and inflammatory bowel disease. 

Research, however, is also showing the role of mast cells in traumatic brain injury, multiple sclerosis, Parkinson’s disease, dementia, Alzheimer’s disease, stress conditions, sleep disorders, migraine, pain, ADHD and autism.

TYPES OF MAST CELLS
Mast cells are everywhere. We have 2 types, the mucosal type ( lining of the gastrointestinal, respiratory and urinary systems which have “mucosa”) and the connective tissue type (in those tissues that hold us, our organs and our blood vessels together, including our skin).   Because they are especially concentrated in places with direct contact with the outer environment (skin, GI tract, bladder, sinuses), they’re our first line of defense against toxins and unwelcome microbes. This is why the more common mast cell symptoms involve the skin, GI tract, sinuses, lungs and bladder.

MAST CELL ACTIVATION
Though patients and parents of patients contact me for their brain related symptoms, such as depressed mood, anxiety, inattention, restlessness, insomnia, agitation, mood, swings, intermittent personality changes or even mania, most also have other physical symptoms of mast cell activation. I’m not sure how much of this is because my practice attracts those with complex illness or because I simply ask about these symptoms - symptoms they might not think to mention.  Nonetheless, one does not to have a plethora of physical symptoms to be suffering the consequences of brain inflammation.

MAST CELL ACTIVATION SYNDROME/MCAS
Those with Mast Cell Activation Syndrome will many signs and symptoms related to the activation of mast cells. Their symptoms are unpredictable and varied.  Below are triggers and symptoms associated with 

TRIGGERS
Common triggers which activate mast cells to release their mediators are:

• specific foods and drinks (especially alcohol, and high-histamine content foods)
• temperature extremes, high altitude, drops in barometric pressure
• airborne smells including perfumes, detergents, chemical smells, or smoke
• exercise or exertion
• emotional stress
• hormonal changes (especially during adolescence, pregnancy and women's menstrual cycles)
• drops in barometric pressure 
• excessive histamine (due to allergens, undermethylation, DAO insufficiency (due to a mutation in an enzyme that breaks down histamine from food in the GI tract.

MAST CELL SYMPTOMS
As you can see there are a lot.  While triggers can vary from person to person, so can symptoms.  Triggers and symptoms can be unpredictable and vary from episode to episode.

General
Fatigue 
Appetite swings - including excessive appetite after beginning to eat
Episodes of low body temperature
Temperature (hot/cold) sensitivity 
Sense of being cold all the time
Difficulty exercising 
Difficulties with anesthesia
Unexplained medication reactions 

Gastrointestinal
Nausea and/or vomiting
Difficulty swallowing, throat tightness
diarrhea or constipation
Gastrointestinal pain or discomfort 
Bloating and gas of irritable bowel syndrome
Liver/spleen pain

Immune
Anaphylactic reactions  - ie. difficulty breathing, itchy hives, flushing or pale skin, feeling of warmth, weak and rapid pulse, nausea, vomiting, diarrhea, dizziness and fainting.
Enlarged lymph nodes
Recurring infections

Reactivity
Medication intolerances 
Chemical intolerance - ie. fragrances or off-gassing in stores 
Reactions to certain foods or drinks
Odd reactions to insect bites or stings

Eyes
Sensitivity to sunlight or bright light
Blurred vision 
Dry eyes 
Eye pain 
Conjunctivitis, “bloodshot” eyea

Ears
Hearing loss 
Intermittent tinnitus 

Nose
Nasal congestion
Sinus infections or problems
Scents/odors/chemical reactions
Nosebleeds

Mouth
Mouth Sores 

Respiratory
Cough 
Wheezing 
Shortness of breath  

Cardiovascular
Chest pain 
Sudden drops in blood pressure
Tachycardia (racing heart rate)

Genitourinary
Frequent urination
Painful urination
bladder/kidney pain

Skin
Rashes
Itching 
Skin lesions or sores
Spots 
Redness
Hives
Flushing
Skin feels on fire
Severe sweating 
Swelling & inflammation
Easy bruising

Musculoskeletal
Joint, bone pain

Neurologic
Headaches
Migraines 
Dizziness 
Lightheadedness 
Fainting /Varying degrees of fainting
Vertigo or problems with balance 
Unexplained weakness  - “jelly legs”
Difficulty walking
Numbness & tingling in face and extremities
Strokes
Nerve pain
Persistent body/tissue pain 

Psychiatric
Intense anxiety or panic attack
Depression
Mood swings
Agitation or anger
Severe fatigue
Insomnia
Brain fog
Problems with memory

Other signs that may be less acute, but are nonetheless related:
Anemia
Easy bruising 
B12 Deficiency
Thyroid problems
Enlarged liver or spleen
Difficult menses (females)
Hair loss
Osteoporosis and osteopenia (including young patients) (m)

LIFE WITH MAST CELL ACTIVATION SYNDROME

Multiple Systems, Multiple Specialists
You may have strange symptoms, and/or you may have a lot of symptoms that by themselves would not be of concern.  You may just think it’s bad luck. Either way, you can’t put your finger on the problem and neither can the psychiatrist, the dermatologist, the neurologist, the ENT, the pulmonologist, the cardiologist, the urologist, the gynecologist, the allergist or the ophthalmologist who all look at  just one of your body systems.

Without answers, you may conclude that in some way you are the problem - it must be anxiety or psychological issues at play.  After all, you seem anxious and depressed. And likely you are - and not just because you are physically sick, or because you’re demoralized by the medical system, but also because your brain is inflamed like other parts of your body. You eventually decide seeking help causes more harm than good. The fatigue leaves you moving through sludge. The brain fog keeps you from being able to organize your thoughts enough to try to solve problems or to make plans.  

The Illusion of Control
If you have even recognized that there are triggers, you become seduced by a seemingly level of control.  Just when you think you have identified and removed the trigger, the rug is pulled out from under you and you’re hit again with what feels like the flu - headache, body aches, depressed mood, fatigue, inattention and whatever mast cell symptoms plague you. Only after the fog clears, if it clears, are you able to wonder about triggers.  When you’re not blaming yourself for your symptoms, you’re trying to figure out what else you could avoid or do to prevent them. You become consumed with your health. Not because you’re a hypochondriac, but because your limbic system is sensing a problem - a danger. And you’re trying desperately to figure it out.

Relationship to Your Body
Your body is not only defying you, it’s triggering you.  With every unusual symptom comes a reminder that things aren’t right. That tests have shown nothing gives you no solace.  How long will it be before the MS or early onset dementia or other yet to be diagnosed neurological condition is advanced enough to show up on tests.  Your mind looks for answers and lands on extremes. You think you're worried because of the symptoms and if the symptoms were gone, that your worries and fear would be too. It never occurs to you that the anxiety might be just another symptom from the same source as the palpitations or the itching and that one isn’t necessarily or only leading to the other. 

Relationship to Others and Work
How can you be so reactive to so many things?  When did you become one of those people who has everything wrong with them; one who can’t harness enough energy or interest to stay connected with friends or even easily engage with those they love. One who has so many abilities, but no fuel, no motivation, and at times not even an ability to care. Caring requires energy. The sick irony is that you don’t look sick. You look normal. You don’t even have a diagnosis to tell people. You may very feel alone even with those you love.

Relationship to the Future
After being knocked down figuratively and literally so many times, you’re afraid to feel hopeful.  Will things ever change? You hope they will, but all the paths (the doctor’s appointments, the avoidance, the dietary restrictions) you’ve taken have only led to shame, isolation and further suffering.  If you have had mast cell activation and brain inflammation, you have likely said to yourself, “I don’t want to live like this anymore,” when you were in the throes of an episode.  I have no doubt that there are many individuals, if not most, who have taken their lives, never knowing that at the root of their suffering was a dysregulated immune system and at that moment of their deepest despair their mast cells and microglial cells were causing their brain to be inflamed. They couldn’t imagine that despair would pass (with the subsiding of the episode) or that this type of inflammation can be treated. 

INSIDE MAST CELLS - MULTITUDE OF MEDIATORS
As I said earlier, mast cells contain granules (little bags) of ready to go inflammatory mediators.  These messengers communicate with other cells and tissues which is another reason there are so many symptoms. You may recognize the names of some of these mediators: histamine, tryptase, chymase, tumor necrosis factor-alpha (TNF-alpha), serotonin, heparin, proteoglycans and vascular endothelial growth factor (VEGF).  And if that list isn’t long enough, another source adds the following inflammatory mediators:  IL-1beta, IL-8, IL-33, chemokine, ligand 2, CCL3, CCL5, GM-CSF, metalloproteinase (MMP’s), ROS, substance P, dopamine, TGF-beta, corticotropin-releasing hormone (CRH), neurotensin, prostaglandin D2, leukotrienes, proteases tryptase and chymase.   

You’ll likely recognize a couple of these neurotransmitters - serotonin important for improving our mood and lowering our anxiety and dopamine important for mood and focus. Perhaps this explains why right before becoming sick, many people will feel especially good and focused or why some children with autism can have great clarity and increased speech right before they become sick.  This might too explain when some people have mood swings from high to very low...very quickly.

OUTSIDE OF MAST CELLS - RECEPTORS
Mast cells not only release inflammatory mediators, they also have receptors for many of those mediators including CRH (which again is a stress hormone released from the brain, but also from other mast cells).  So, when mast cells “degranulate” or dump out the contents of those granules, those mediators can communicate with other mast cells. When mast cells are activated, lots of things can be released to fight threats, but when they are  persistently activated  (because of a persistent threat) some of these mediators can destroy surrounding tissue.  

EXAMPLES OF EXAGGERATED IMMUNE RESPONSES
Though it’s not so hard to imagine how an exaggerated immune response could cause someone to breakout into hives, have an asthma attack or even go into anaphylaxis after eating a peanut, it’s less obvious how an exaggerated immune response affects the brain.  Consider the similarities between how one might feel if they have the flu (fatigue, brain fog, down mood) and if they have depression.  They’re not so different, just one is lasting much longer.   More dramatic are the similarities between anaphylaxis and panic attacks.

Anaphylaxis - a mast cell mediated allergic response that occurs within minutes (or even up to 30 minutes) after exposure to an allergen (like a peanut). 
Symptoms include:
hives
itching
flushed or pale skin
Low blood pressure (hypotension)
Constriction of your airways and a swollen tongue or throat, which can cause wheezing and trouble breathing
weak and rapid pulse
Nausea, vomiting or diarrhea
Dizziness or fainting

Panic Symptoms come on suddenly and can be triggered by certain situations. 

• Shortness of breath
• Dizziness
• Nausea and/or abdominal cramping
• Racing heart rate
• Chills or hot flashes
• Sweating
• Headache
• Tingling sensations on the skin
• Derealization
• Chest Pain
• Tunnel vision
• Agitation or Aggression

So yes, while a peanut in one person can trigger anaphylaxis, an emotional trigger (ie. a sensation associated with a traumatic event, or an upsetting thought) can trigger mast cell activation and thus a panic attack.  Despite the classic understanding of panic, it is very likely that a lot of people having panic attacks are reacting to physiologic triggers (ie.something they ate or inhaled) as opposed to psychological triggers.

WHERE THE IMMUNE SYSTEM & BRAIN MEET

Blood Brain Barrier and Gut Blood Barrier
When mast cells are stimulated they disrupt and release mediators that increase the permeability of what we call the Blood Brain Barrier (BBB) and Gut Blood Barrier (GBB). 

The blood brain barrier is the barrier between our blood (which is carried throughout the body through blood vessels) and our brain.   If you are an unwelcome toxin or microbe that has been ingested and you make your way through the gut blood barrier, into the blood and then up and through the blood brain barrier, the neuroimmune system is going to try to get rid of you. When the body has more toxins or unwelcome microbes than it can manage, there can be an exaggerated immune response impacting surrounding brain tissue. 

Microglial Cells
Mast cells can also recruit other inflammatory cells and activate microglia (the immune cells in the brain).  Though they're there to clean up unwanted dead cells and repair brain tissue, if they’re getting too much activation, they will release their own inflammatory mediators causing local inflammation and disrupted connections between neurons.  If this goes on too long, nearby neurons will die which leads to neurodegeneration which can equate to the beginning of dementia. This is why there is a strong correlation between brain related disorders in younger people, ie children with ADHD, or adults with depression, PTSD, head trauma and later dementia.

EVALUATION 

While there is detailed, complicated and not terribly reliable testing for mast cell activation, I rely on in-depth questionnaires, a thorough history and a response to treatment as my guide, including:

• Detailed family history - usually there is evidence of mast cell activation related diagnoses. Fitting with RCCX theory, joint hyper-mobility (being flexible, double jointed, etc) is a red flag for mast cell activation.
• Very detailed “review of symptoms” - including all the symptoms above (and others that might point me in other directions)
• Very deep timeline - listening for early attachment disruption, emotional or physical trauma, including head trauma, environmental and toxic exposures, evidence of infections (Lyme, bartonella, etc).
• Inquire about triggers - if known
• Because there is such a strong association with mold toxicity, a detailed environmental history is part of the timeline - if the person has ever lived, worked or spent extensive time in spaces with water damage (not that it’s always known)

TREATMENT

• Education, education, education.  This is a double-edge sword.  On one hand, it helps the person, step outside of their symptoms and watch what is going on, to see it as inflammation that usually will pass, and that treatment can help to lessen their symptoms while we identify what is causing the inflammation in the first place. On the other hand, learning that one’s symptoms may be due to certain triggers such as certain food, or weather changes, etc, if someone has not already started to realize this, can lead to a level of vigilance that can problematic in of itself and even triggering.
• Avoiding known triggers (for that person) - this could be hot baths, overeating, skipping meals, perfumes, big box stores, a narcissistic family member
• Stabilize mast cells (so they’re not releasing all those mediators) - There are a number of interventions that can help with this. Sometimes layers of various interventions are needed. My favorite 2 are:
  • Quercetin (with or without Bromelain) - if taken 30 minutes before meals can stabilize mast cells in the gastrointestinal tract, so that eating itself isn’t leading to a level of mast cell activation. 
  • CBD oil - has been shown to help with depression, sleep, anxiety and pain, likely in part because of it’s mast stabilizing effects.
  • Others
    • Natural supplements - Perimine, AllQluer
    • Medication - Ketotifen, Cromolyn sodium
• Block Histamine Receptors - If we could completely stabilize mast cells, we wouldn’t need antihistamines, but we do both to provide as much relief as possible.  Histamine is just one of the mediators that mast cells release, but one that can further trigger mast cells to become activated.  It can cause a lot of well known physical symptoms (skin issues, upper respiratory allergies), but also brain fog, fatigue and depression, especially for those who are undermethylated and because of this don’t break down histamine very well.
  • Antihistamines  (to block H1 receptors) - While many people with simple seasonal allergies can benefit from one 24 hour antihistamine, those with mast cell activation often can benefit from one twice a day or even three times a day.  Surprisingly to many, this can help with brain fog, fatigue and even addictive type behaviors that histamine seems to drive.
  • H2 blockers (to block H2 receptors) - which decrease stomach acid (ie. Zantac and Pepcid). Though not an approach I typically use, I mention it, because it is a common approach to treating mast cell activation. 
• Remove Sources of Histamine and Inflammation
  • Lower allergen exposure:
    • Respiratory
      • Air purification (even if simply making your own $25 one with a box fan, air filter and duct tape.)
      • Allergy covers for bed and pillow
  • Anti-inflammatory, and if necessary, histamine lowering dietary changes 
    • Sugar is inflammatory for everyone for a number of reasons 
    • Gluten and Casein - most people with brain related symptoms can benefit from taking these out of their diet
    • Any other known food that one is reacting to.
    • There are foods that are especially high in histamine. Some people with mast cell activation will feel better removing these or taking a DAO/Diamine Oxidase supplement to breakdown histamine in the GI tract prior to a high histamine meal. 
      • Products of fermentation are high in histamine - ie. wine and other forms of alcohol, vinegar (in a lot of sauce type products, ie. ketchup, mustard, mayo, etc. soy sauce, yogurt, kefir, kombucha)
      • leftovers, especially left over animal protein - beef, chicken, pork, fish, etc,
      • beef (because it goes through an aging process) is higher in histamine than chicken
      • Avocado, cinnamon, citrus, tomato products are also high in histamine
      • See histamine ratings for specific foods
• Address Toxicity.  In my experience, mold toxicity, because of the way it disrupts the immune system is the most common cause of mast cell activation.   Because removing mold toxins (and other toxins) and treating mold colonization or other biotoxin related illness (Lyme, bartonella, etc.) can trigger mast cell activation, stabilizing mast cells and blocking histamine receptors, for some people, can make the treatment move along more smoothly.
• Address Digestion & the Microbiome. Undigested food in the lower digestive tract can be a source of fermentation, toxicity and inflammation.  Some individuals can benefit from support with digestive enzymes and a supplement called Betain Hcl. If mold toxicity is present, which again in my experience, usually is, then removing mold toxins and treating yeast and mold in the digestive tract become the priorities. Many individuals can’t tolerate probiotics or anti-fungal herbs, supplements or medication until the mold toxins are starting to be removed with mold toxin binders. 
• Address Nutrient Status - Because I’ve written about copper overload, undermethylation and pyrrole disorder in other posts, I won’t focus on those here, but know that rarely does someone have mast cell activation or nutrient imbalances in isolation.  Those who are vulnerable to nutrient imbalance and those with mast cell activation are overlapping (if not the same) populations. In fact if you look closely at the list of pyrrole symptoms you will see that most are similar to those of mast cell activation ( and connective tissue symptoms). It is arguable that pyrroles are actually the waste product of the weakened enzyme (21 hydroxylase) that 15-20% of us may have. It does have a pyrrole structure in it.As for methylation, we need methylation to break down histamine.  If you are periodically being slammed with histamine because of mast cell activation and you are undermethylated and thus don’t break it down well, then you likely would be symptomatic before someone who is not.

And last, but not the least....

• Address the Hormonal Stress Response - It’s easy for one to hope that supplements and medication will do all the work, and not take this piece about lowering stress in their lives seriously.  If people don’t heed this in the beginning, they often will learn that their healing is dependent on them addressing the faulty rewiring that can occur as a result of mast cell activation and brain inflammation.  On the other side of all of these health issues, most people find that they have disassembled and rebuilt their lives In ways they never would have but for becoming sick. Self-care becomes a priority along with attention to diet, sleep and exercise (as tolerated).  Healthy relationships with appropriate boundaries becomes the new standard.  Work that might have once been stressful and mostly ego promoting is replaced by work that is more satisfying and meaningful. 
  • Neural Retraining. This treatment is specific to mast cell activation. One in particular is the Dynamic Neural Retraining System, created by Annie Hopper.  A similar program that I have less experience with is the Gupta Program Brain Training. Both are based on the understanding of neuroplasticity and our ability to essentially rewire our brain to strengthen pathways that are less triggering for us. Even before addressing toxicity, there can be dramatic results.
  • Befriend Your Body that you have felt at odds with and triggered by for some time.  The body is where we ultimately find calm (as opposed to our head) - yoga, breathing, stretching, walking, dancing or any form of movement.
  • Practice Gratitude - this is part of rewiring the brain - it helps us scan our days, lives for the good. The more of this wiring the less room there is for fearful, vigilant and triggering wiring that can be inevitable for some who have dealt with these symptoms chronically.
  • Learn and Practice Embracing Uncertainty. This may sound like a spiritual approach.  It is. As long as we think things need to turn out a certain way, we are creating stress in our lives and in our bodies (and brain tissue). Yes, we can set goals, do our hard work and have our desires, but hold them gently, don’t grasp too tight. Stay open and curious of what will unfold.
  • Learn to be Mindful and Present - Use whatever practice works for you. Learn to meditate, do art, sing, do anything that opens your mind up and moves you away from the detail thinking.  
  • Exercise your right hemisphere - again give your left hemisphere, which hones on every detail, a rest. There  are a number of feel good strategies in my last post.
  • Access the Vagus Nerve - which I look forward to writing about in a future post.

THE INFLAMED COLLECTIVE
People in families, in workplaces, school or even larger communities where there is a shared toxic environment can be unknowingly dealing with consequences of collective brain inflammation. I have little doubt that many marriages have ended because of brain inflammation. It’s not a stretch to see how living in our increasingly toxic and stressful world could be contributing to a collective that is less happy, less focused, less engaged and with greater suffering.  Mast cell activation and brain inflammation aren’t new.  They’re just becoming increasingly common as can be seen by the dramatic escalation in associated medical and psychiatric conditions.

THE PIONEERS (from my perspective)

MAST CELL ACTIVATION
Dr. Lawrence Afrin (MD) wrote the pioneering book, “Never Bet Against Occam: Mast Cell Activation Disease and the Modern Epidemics of Chronic Illness and Medical Complexity”
He and the mast cell community that follows his work are especially focused on the diagnosis and treatment of mast cell activation (and seemingly less on root causes such as mold toxicity or even a stress hormone pathway vulnerability).  If you want to dig deeper into the physiology and available testing, I would highly recommend his book.  
Dr. Theoharis Theoharides’ (MD, PhD), Professor of Immunology and mast cell researcher at Tufts University was the first to show that mast cells can be activated by CRH/corticotropin-releasing hormone, which is huge in understanding the onset of disease or worsening of disease when under stress.

RCCX THEORY
Dr. Sharon Meglathery (MD), a psychiatrist and internist described RCCX theory - a brilliant and complex theory that explains how some (15%-20%) of us are wired for mast cell activation because we have a weakened 21 hydroxylase enzyme) due to a range of mutations on the gene for it).   Because of this, we have more CRH being released when under physiologic or emotional stress. This theory (in addition to connecting a number of other dots) drives home the importance of addressing inflammation by addressing this stress response in those with psychiatric and chronic medical illnesses.

MOLD TOXICITY & MAST CELL ACTIVATION
Dr. Neil Nathan (MD) is a pioneer in the treatment of mold toxicity and complex illness.  He is also the author of “Heal Your Body from Mold Toxicity, Lyme Disease, Multiple Chemical Sensitivities, and Chronic Environmental Illness,” and my mentor. He and many others in the environmentally acquired illness community are not focused on RCCX theory, and find mold toxicity to be the most common root cause of mast cell activation. They also find that when mold toxicity is treated (which can take time) mast cells typically settle down and the inflammation (in the brain and body) become less of an issue.  That being said, interventions that lower the stress response, such as DNRS are regularly prescribed tools for treating mast cell activation while addressing mold and other forms of biotoxicity.

LASTLY,...
FOR THE READER WITH BRAIN INFLAMMATION &/OR MAST CELL ACTIVATION:
It’s always my hope that sharing some of what is being learned will help someone out there reconsider the stories they have about themselves, their symptoms and even their lives.  It is my hope the next time someone has a panic attack, an episode of depression, a tantrum out of the blue, severe brain fog, fatigue or even a suicidal thought, that they’re able to pause and be curious instead of being swept away by their faulty beliefs in that moment.  Even if you don’t remember anything I said about mast cells, microglial cells or CRH, ​I hope you remember the term brain inflammation. I hope you can consider what you’re feeling isn’t a failing on your part, but instead, the way your immune system is telling you there’s a problem that needs to be addressed. And lastly, I hope you remember that despite brain inflammation and all the suffering it can cause, it can be treated and there can be a life of thriving on the other side.
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Other resources:

• Mast Cell Activation in Brain Injury, Stress, and Post-Traumatic Stress Disorder and Alzheimer’s Disease Pathogenesis
• Mast Cells and Neuroinflammation

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Courtney Snyder, MD

I first met Dr. Walsh in the fall of 2014, at his second physician training course here in the US.  At the time, I was uncertain how useful nutrients would be in my psychiatric practice.  What I learned seemed too good to be true. Upon returning home, I gradually began evaluating and treating specific nutrient imbalances in adults and children with depression, ADHD, anxiety, bipolar disorder, autism spectrum disorders, and so on. To my repeated surprise, most patients - children and adults alike improved… significantly - some dramatically, including those whose symptoms had failed to respond to other treatments.  

Courtney Snyder, MD

​We’re not necessarily the same animal we once were.  And, in many respects, especially when it comes to food, we’re increasingly different from one another.  Describing a particular food (or nutrient) as “good” for you, depends on who “you” are.  Due to our varied experiences, exposures (ie. to antibiotics, toxins, etc.) and genetics, we’re not all the same.  The latest superfood may benefit some, but it may make others ill.  Our complicated relationship with food can’t be discussed without considering inflammation, oxidative stress and epigenetics - the three exploding areas of medical research. ​

Courtney Snyder, MD

Purpose, Healing and Happiness
Whatever language, symbolism or religious framework we use or try not to use, many of us believe there's a reason each of us are here ...at this time, in this place and with these people.  Though I think a lot about the details of health, I fall short on the bigger picture of healing if I forget that our wellbeing depends on much more, not the least of which is having a deep sense of purpose in our lives.

Purpose can energize us. It is a reason to do the hard work; to get out of bed.  It lowers stress and it’s associated physiologic responses. Futility is stressful.  So is incongruence - the mismatch between our natural abilities and passions and what we’re actually doing. With purpose comes a clarity about what and with whom we want to spend our time. ​

Courtney Snyder, MD

​Though steeped in nutrition professionally and personally, I don't like to spend a lot of time in the kitchen. Most of what I prepare has very few ingredients, though the ingredients are whole (unprocessed).  And most of my food preparation has very few steps.  I'm hoping my culinary limitations, which I've honed over these past few years, will be useful to someone else.

Before getting into the below "recipes", I should add,
I believe...

​By Courtney Snyder, MD

...is ragus - an Aran Island's word for 'desire' or 'urge.’  The Aran Islands are off the west coast of Ireland and have little to do with this post, except maybe to help draw in unsuspecting readers.

Like me, you may wonder,... "Who really wants to read about the problems with sugar?"

Over these past four weeks, I considered many approaches:

I’d be inclusive and point out that despite great individual variability in how our bodies react to foods, science is showing that limiting or avoiding sugar makes good sense for...well...pretty much everyone.

I thought I’d be investigative - I’d give an excessive list of names for hidden sugar on food labels.  I’d give examples of how much sugar is in “savory” foods - ie. 1/2 cup of tomato soup has 3 tsp. of sugar.  For those into calculations, 4 grams = 1 tsp.

By Courtney Snyder, MD

Historically we've considered mental health and illness as coming from either one's life experiences or coming from one's genetics or biology.  We've mistakenly considered the mind separate from the brain and the brain separate from the rest of the body.  We are more interconnected than those outdated views suggest.  Our physical health impacts our brain health. Likewise, we experience emotions (fear, anger, sadness, and joy) not only in our brains, but in our bodies.  Emotions influence our brain's biochemistry, and our biochemistry impacts our emotions and how we experience our lives. 

PYRROLE DISORDER

A perfect example of this is Pyrrole Disorder - a biochemical abnormality that causes the overproduction of pyrroles.  Pyrroles are a metabolite of hemoglobin (a protein in red blood cells that carries oxygen throughout the body).  Pyrroles are not a problem and do not cause disease.  We all have them. They do however, bind Vitamin B6 and Zinc.  When pyrroles leave the body (through urine), they take some B6 and zinc with them.  This is not a problem either.  The problem comes when pyrroles are being overproduced for genetic reasons or because of physical or emotional stress.  This can lead to severe B6 and zinc deficiencies.  

By Courtney Snyder, MD


I never like to hear, “You should….," Whether it’s a well intended friend, or a facebook link on how to “IMPROVE YOUR HEALTH IN JUST 5 MINUTES A DAY.”    The suggestion that anyone knows the right answer for all of us is annoying. When it comes to health and happiness, there's no one size fits all.  Some of us need more protein, some of us need more vegetables; some of us need to minimize toxic exposures, some are less vulnerable; some of us need more routine, some of us need more spontaneity; some of us need more self care, some of us need to give more of ourselves; some of us need better boundaries, some of us need more connection.  Within each of us is a knowing of where that balance is.  The trick is being open to new information, while trusting and listening to that knowing part of ourselves.

All that being said, I do believe that whoever you are, IF YOU DO THIS ONE THING FIVE MINUTES A DAY, IT WILL IMPROVE YOUR HEALTH AND HAPPINESS! If you think you just heard the enthusiastic voice of the television spokeswoman selling the latest exercise gadget, then you've heard correctly.

Courtney Snyder, MD

Before I delve at length into the amazing process of methylation and it’s impact on personality and mental health, I'll lay some groundwork.  For those who don't need or want such background, I've tried to make it easy for you to hit the highlights or jump ahead to your own starting point. 

Courtney Snyder, MD

In these next couple weeks, as we help our children collect needed supplies for school and other activities, let us remember to have inner authority high on the list.  (I wrote this post for my other blog a few years ago. I hope it is still useful now).

Reclaiming Inner Authority in a Hierarchical World Gone Mad
(November 10, 2011) by Courtney Snyder, MD

Last week I saw a clip from the Jimmy Kimmel Show in which he asked parents to post videos to Youtube of children’s reaction after they (the parents) tell them they've eaten all their Halloween candy.  From an overwhelming number of videos posted, Kimmel shared a few.  Why were those parents so up for a task in which they inflict emotional pain on their children, video tape it and share it with the world?   Who was so insensitive to them when they were children? 

“It was just a joke,” “Where’s your sense of humor,” “You’re no fun,” is how some might respond.

Courtney Snyder, MD

What is the microbiome and why are so many researchers studying it's impact on human health including mental health?  How can we take care of it?  And, what can it teach us about fear, the importance of diversity and our relationship with the natural world?

The microbiome is the collection of microbes that live on and in our bodies.  There are estimated to be 100 trillion in our gastrointestinal tract - about ten times the number of cells in our body. Spread out, it is believed these microbes could cover a football field.  Though there are an estimated 500 -1000 different species, only one third seem to be common to most people.  The other two thirds are specific to each one of us.  So, along with our unique experiences and genomes, we have unique microbiomes.

Courtney Snyder, MD

Expectation - the pervasive force that can deflate some of our happiest moments. Expectation makes us hold too tightly to what we think should happen or how we think someone should respond to something we've done. Disappointment often follows. ...But, do we have to live with expectation? 

I started wondering about this while volunteering with my family alongside a couple whose organization gives food, friendship and dignity to people living on the streets. Without naiveté about addiction, mental illness and homelessness, this couple never seemed to question whether or not they should give.  Their intent was to serve.  How many of us have questioned the best way to give to a homeless person fearing if we give money, they’ll spend it on alcohol, drugs or cigarettes. While it makes sense, not wanting to participate in a possible addiction, it also raises an important question - Are we actually "giving" when we need to have certainty of the outcome?  

Courtney Snyder, MD
 
Psychiatric medications are a good thing ...for a lot of people....at least at this time in the history of medicine. They save lives and alleviate suffering and pain.   

Courtney Snyder, MD

Have you ever tried so hard to solve a problem, that you couldn't see the answer right in front of you?

I had that experience after a long period of pursuing health challenges for my daughter and me.   We'd made good progress and with my new found energy and focus, I quickly shifted my attention to something else to relentlessly work on - my career.   I knew I didn't I want to return to the kind of psychiatric practice I had previously.  I couldn't imagine an alternative, despite just having spent a good part of a decade immersed in the relationship between nutrition, the gut-brain connection, and autoimmunity.

Courtney Snyder, MD


“The journey of a thousand miles begins with a single step.”

― Lao Tzu

I don't recall that step...maybe it was when I first asked for help for my daughter.... or maybe, when I decided to stop asking - when I realized that conventional medicine did not have the answers for us. Either way, my experience into illness and healing forced me to let go of many assumptions and expectations I had about the world, about life and about myself.

My hope in starting this blog is to share what I've learned so someone else won't have to search as I have these past ten years.  Though at times frustrating - the seeming snail's pace of such a pursuit - there are many who will never look beyond what is in front of them, many who will never cross paths with those who might point them in unexpected directions and many who when given leads, will never pursue them.   If you are reading this, perhaps you too are a seeker.