RHR: Uncovering the Hidden Causes of Anxiety and Depression, with Dr. Kenneth Bock

In this episode, we discuss:

• The increasing rate of 12- to 17-year-olds suffering from mental health disorders
• The biological underpinnings of many common mental health issues
• How triggers such as gluten sensitivity, adrenal dysfunction, Lyme disease, and post-strep infections create imbalances in the body that can generate psychological symptoms
• How conventional medicine often treats these issues with medications that are designed to address the symptoms but are not touching the fundamental root cause of these disorders
• Other conditions that need to be considered, including nutritional imbalances, metabolic imbalances, hormonal imbalances like thyroid or adrenal dysfunction, and reactive hypoglycemia
• Which labs and blood work are most helpful for identifying these underlying causes

Show notes:

• Bock Integrative Medicine website
• Brain Inflamed: Uncovering the Hidden Causes of Anxiety, Depression, and Other Mood Disorders in Adolescents and Teens by Kenneth Bock
• The Road to Immunity: How to Survive and Thrive in a Toxic World by Kenneth Bock
• Healing the New Childhood Epidemics: Autism, ADHD, Asthma, and Allergies by Kenneth Bock
• Learn more about the Adapt Naturals Core Plus bundle or take our quiz to see which individual products best suit your needs
• If you’d like to ask a question for Chris to answer in a future episode, submit it here
• Follow Chris on Twitter, Instagram, or Facebook
• Get your free LMNT Recharge Sample Pack when you purchase any LMNT product at Kresser.co/lmnt

I’ve had the pleasure of treating many kids and teens in my practice over the past 15 years, and as you might imagine, behavioral and mental health conditions [such as] anxiety, depression, [obsessive-compulsive disorder] (OCD), panic attacks, [attention-deficit/hyperactivity disorder] (ADHD), and a whole range of issues [are] quite common in that population. We know that from statistics, and it was no different in my work [experience] with these kids and teens. And I was always struck by the surprise that parents would express when I suggested that the roots of their children’s condition might actually be physiological. Things like gut dysbiosis, nutrient deficiency, chronic infections, or other inflammatory conditions that were driving the psychological, behavioral, and emotional symptoms that their kids were experiencing. In fact, in many cases, no doctor previously had ever suggested that. It wasn’t even on their radar. They were purely treating it as a psychological or behavioral disorder, often with medications that were designed to address the symptoms but were not touching the fundamental root cause of these disorders.

So I’m very excited to welcome Dr. Kenneth Bock as my guest today. He received his MD from the University of Rochester School of Medicine in 1979. He’s a fellow of the American Academy of Family Practice and the American College of Nutrition. [He] is a certified nutrition specialist, as well, and the founder of the Bock Integrative Medicine Clinic in Red Hook, New York. He’s been a pioneer and leader in the field of integrative medicine for four decades. He’s the author of several books, and most relevant to the conversation today, he is an expert on the new childhood epidemics of autism, ADHD, asthma, and allergies. In particular, he has done a lot to bring our attention to the physiological roots of these conditions [and] how some of the things that I just mentioned—nutrient deficiency, gut dysbiosis, tick-borne infections, [and] other types of infections—can be either primary or at least contributing factors to these psychological and behavioral health conditions.

I’m really excited to talk with Dr. Bock about this because, as I said, there’s not enough awareness in the general community about that link, and it’s the fastest way to make progress on these conditions in many cases. So I hope you enjoy this conversation as much as I did. Let’s jump in.

Chris Kresser:  Dr. Kenneth Bock, [it’s] such a pleasure to have you on the show. I’ve been really looking forward to this.

Kenneth Bock:  My pleasure to be with you, Chris.

Chris Kresser:  So, I have been treating kids and adolescents and teens for some time, [and] you for quite a bit longer, I think. You have four decades of experience in this field. And one of the things I’ve always been struck by when I would treat a child and oftentimes, one or both parents is there, and I would suggest the possibility that their ADHD or depression, anxiety might have a physiological or biological root, like disrupted gut microbiome or chronic infection, a tick-borne illness, [or] nutrient deficiency, the response was often huh? Or something like, no one had ever suggested that as a possibility. It was never really even on the radar. And often, they were relieved because there was something that they could possibly address or some cause or reason that could make sense for what was happening.

But I’m just curious, when did you become aware of this in your career? And what has your experience been over the past 10 years, let’s say, in terms of the awareness of this in the medical field, and in the general public?

Kenneth Bock:  It’s kind of two questions. Let me take the first one because that goes back more than 10 years.

Chris Kresser:  Sure, of course.

Kenneth Bock:  This is my 40th year. You make me feel a bit older there, Chris.

Chris Kresser:  It’s great experience. Experience is valuable.

Kenneth Bock:  You know what? I actually think it’s invaluable because when you’ve seen thousands and thousands of kids like I have, you really, I tell parents, they have an n of one. And when you have n of thousands, it really makes a difference in how you can treat. But it was really interesting. It dates back to the first book I wrote [in] 1997, called The Road to Immunity. And at that point, I was really researching the immune system, and talked a little about this, these little peptides called transfer factors. Somebody had read it and got in touch with me, and I started to do some research and transfer these little tiny peptides that are immune modulators. That means they balance the immune system. And then, and I was really looking how it affected at that time, Th1, Th2. There really wasn’t a lot about Th17 at that time; I think it came after. So it was mostly Th1, Th2. It wasn’t always clear-cut, but I was doing a lot of research. And [an] autism society got ahold of my writings, my research and asked me to speak. And I spoke at this conference, probably a thousand parents, and I was, they didn’t know me, really. So I was at the end of the conference, one of those things that we, they (inaudible 03:18). And because I had this integrative medicine approach, it really hit the parents and the practitioners in the audience.

Anyway, to make it short, a lot of the parents started to bring kids [on the spectrum] to see me. And I had a lot of success with an integrative medicine approach because I figured out that over time, you had to (inaudible 03:40) the kids, just like what you said, with all the different kinds of potential causative factors. And that was microbiome and infections and autoimmunity and inflammation. Inflammation was the underlying thing for so many of the kids. And as parents started to travel from all over the country, and then eventually all over the world, they [would] bring their other kids and they [would] say, hey, would you mind? I know they’re not on the spectrum. Do you mind seeing so and so, and so and so who has anxiety or depression or panic attacks or OCD, mood dysregulation? And I said, sure. And applying the same approach, I was able to find that so many of them were also affected by so many of these underlying medical, biological conditions, including inflammation, and specifically, brain or neuroinflammation. So eventually, after at least 10 years, or that at least, I said, you know what? I really have to try to put this together. Because it’s not just the spectrum that I had seen so much. It was all of a sudden, hundreds and thousands of kids, neurotypical kids, some of who[m] were, like quote, normal and then deteriorated really rapidly in terms of, an infection driving brain and autoimmunity. So that’s really what drove me to it.

Chris Kresser:  And what it’s been over the past 5, 10 years? Are you seeing more acceptance of these ideas among your colleagues? Or has it still been a challenge in that regard?

Kenneth Bock:  Now, definitely more acceptance. There’s no question. There’s more and more research out there. So, when we first started, it was interesting. I mean, it’s like, my whole career has been defined by treating conditions that became so obvious to me, yet, many physicians didn’t believe existed. Reactive hyperglycemia, that physicians still don’t believe exist[s]. Chronic candidiasis or fungal dysbiosis. Now, of course, the microbiome is huge. But when we first started, and I’ve been doing work with the microbiome my whole career, they didn’t (inaudible 05:43). Come on, you’re giving me probiotics? No, really, you look at Lyme disease. So I spent the beginning part of my career treating all these kids with recurrent ear infections who [were] getting antibiotics. And we had to find out that they had a milk allergy, or they had chronic Candida and dysbiosis and things. And now, I treat so much tick-borne disease with antibiotics because, and then now, they don’t believe there’s chronic Lyme, that you don’t need. So it’s really interesting.

So for this whole thing of what is usually referred to as PANS [(Pediatric Acute-onset Neuropsychiatric Syndrome]), and PANDAS [(Pediatric Acute-onset Neuropsychiatric Disorders Associated with Streptococcus)], I don’t actually like to use those terms as much because of the, quote, controversy in some physicians. So I like, as you read the book, infection-triggered autoimmune encephalitis or in late terms, infection-triggered autoimmune brain inflammation, which I think really kind of sizes it up for the most part. And I think laypeople have really, the parents had [the] ability to understand that. So I do think to get around to the answer is that there is more acceptance, no question. But they weren’t for a while. And they still are, but there are less pockets. I mean, places where, because in the medical school, I’m not going to give a name because I don’t want to sound like I’m (inaudible 06:58) the place. But [at] a really well-known medical school in another state, the pediatricians would say, “Well, our doctors, the medical school, don’t believe in this; therefore, we don’t believe in it.” It would literally be, we don’t believe in it. So how can you not believe in it? A kid is normal. They get an infection. They rapidly become an alien, with all these [neuropsychiatric] symptoms that can be so severe, but we don’t believe it exists. But thankfully, that’s changed.

Chris Kresser:  Yeah, I’m thankful for that changing because it’s hard enough to be a parent with a child who’s struggling with those issues. But then, if you go [to] the doctor and report it, and you’re made to feel you’re imagining it, that’s still brutal for a parent to deal with. And I’ve had so many parents over the years come to me in tears basically because nobody believed them. Their experience wasn’t valued as a parent. And they were just told that it was some kind of imaginary thing that they and their kid were making up. It was a horrific experience. And I mean, I love what you said about Candida and fungal overgrowth because that was, if you were to [mention] fungal overgrowth or Candida at a medical conference, that was probably a surefire way of getting yourself laughed out of a room or eye rolls or whatever. And now you look in PubMed, and you can find papers correlating fungal dysbiosis with Crohn’s disease and inflammatory bowel conditions and all kinds of stuff. It’s all there in the literature. And people like yourself and Leo Galland and others have been talking about this for years but not being taken seriously. And now that we have the published research to support it, it’s sort of a tacit, oh, okay, I guess there was something to this all along.

Kenneth Bock:  That’s not always said, by the way, Chris. Sometimes, it’s like, we just discovered it. This is like a new discovery.

Chris Kresser:  Right, exactly, yeah. Look what we found. Anyway, it’s [a] positive development for all of us that this is now being accepted, at least within the scientific community. As you said, it hasn’t necessarily percolated down. I’ve often found, and I’m sure you have, there’s a 10-, 20-, even 30-year gap between what’s showing up in the scientific literature and what you might find with your primary care provider, even in medical schools. Which, ironically, can be the last to change because they’re just so deeply entrenched in the current paradigm, right?

Kenneth Bock:  Yeah. I mean, I wouldn’t have the time. But there’s a whole story about penicillin.

Chris Kresser:  Okay, yeah.

Kenneth Bock:  We don’t use it at the medical center. How could it be? How could it work?

Chris Kresser:  Right, well, I want to dive in. There’s a good segue, you mentioned, just calling these conditions what they are, an autoimmune inflammatory reaction in the brain. And let’s talk about some of the mechanisms here and the causes. We’ve mentioned the gut microbiome, dysbiosis, infections, and things like that. But let’s talk a little bit about how, for example, [a] disrupted microbiome might lead to inflammation and an autoimmune attack against the brain. Some of the research that’s come out around gluten and gluten’s effects on the brain in certain kids, whatever direction you want to go is fine. But I think it’s helpful for parents to understand some of these mechanisms, at least at a high level.

Kenneth Bock:  The gut–brain connection is so key. And I have to say, it’s been a key for those of us in this field, for so long, with anything from arthritis, to dermatitis to vein issues. You can treat brain fog and all this confusion with an antifungal, and it goes away. You didn’t give anything, quote, for the brain. So the key is that there are many things that can cause the intestinal lining to become more permeable, and that can range from gluten and casein, these are dietary peptides, to all kinds of infections, anything from viral to bacterial or fungal to parasitic, toxins, even some drugs; there are so many things that can do that, and even stress. And when the gut becomes more permeable, and in lay terms, we call them leaky gut. But in medical terms, it’s intestinal hyperpermeability. There are these tight junctions, and they’re important, because if you think of what, people only think of what they shovel into their mouth and in their guts on a daily basis is pretty scary. So the gut has to be able to discern what it can let through, what’s friend, what’s foe, what it has to react to, and you don’t want it reacting to everything because you’re going to be in trouble, especially if it’s good stuff. So when something affects the gut, makes it more permeable, it loosens these tight junctions. Allows these mediators, whether they be metabolized from the microbiome to any kind of inflammatory mediators that are initiated by whatever is happening, whether it be an infection, or gluten or what have you. And it gets into the circulation, gets up to the brain. And then quite frankly, I have slides that show that the actual connections between the endothelial cells, which are these single cells that are in the tiny capillaries in the brain, that’s where all the action is. They have tight junctions in the same way. And those tight junctions get loosened. And then you have a leaky gut, leaky brain. You have a leaky blood–brain barrier. And that allows all these inflammatory mediators, whether they be immunoglobulins, because they’re pretty large, they’re large molecules, and these inflammatory immune cells, and then they wreak havoc on the nerve cells and the companion cells in the brain. So that is the connection.

And if you don’t heal the gut, you don’t get people better. But that’s with this brain inflammation, that’s also with arthritis, and it’s also, the gut is so key. So that’s why we really, that’s really one of our main focuses. And if a kid is constipated, and the kid is having all these [gastrointestinal] (GI) issues, you really have to tend to that first or they won’t get better.

Chris Kresser:  Yeah, I’ve seen, it’s almost like show me a kid with a behavioral disorder, [and] I’ll show you a kid with a gut disorder. It’s maybe not a one-to-one correlation, but it’s pretty darn close in most cases. And they may not even come into the clinic complaining of GI issues, or maybe the psychological behavioral symptoms are more prominent. But when you do a history and you start asking questions about how frequently [do] you have [a] bowel movement? Oh, once every three or four days. It’s not something that’s even on their radar as being abnormal or something that needs to be addressed. But it’s certainly a contributing factor. And I mean, is it any wonder with antibiotics, highly processed and refined foods, all of the dyes and processed foods that kids are exposed to, all of the other things that threaten the gut microbiome these days. We’re really now seeing in the last two generations, the effects of these changes.

Kenneth Bock:  100 percent, 100 percent.

Chris Kresser:  Yeah. So, aside from the gut–brain axis, what are some of the other, and everything that goes along with that. I mean, that is kind of a foundational factor, even with some of these other challenges that we might talk about. But you mentioned chronic infections. What are some of the other things you tend to look for when somebody, a kid or adolescent or teen comes and presents with these behavioral or psychological conditions?

Kenneth Bock:  I don’t want to skirt over the chronic infections because they can be acute infections like strep, which is the classic initial, it’s an immune response. And I think people need to understand that when your immune system reacts to an infection like strep, it recognizes and it makes these antibodies. It has T cells that get into the fray, and also these antibodies made by B cells. But there are these what’s called epitopes on the strep. These are very, very tiny parts of peptides, extremely small. But one of those epitopes can look exactly like a piece of the basal ganglia in the brain. So when your immune system makes antibodies to strep, it may see this part of the brain called the basal ganglia and react to that thinking it’s strep. We call it molecular mimicry. So that’s one of the pathophysiology mechanisms of how it happens, in addition to these T cells, inflammatory T cells. So strep is one.

And the last patient I had today [had] acute recurrent strep infections. A six-year-old from January through this year, five, and every time, he never had a sore throat. All he had was mood dysregulation, hyper ADHD, vocal tics, and loud noises. And finally, somebody recognized and then referred him to me, because they recognized that it was the strep that was doing this. So that’s strep, but I think the tick-borne is something I want to really emphasize, because that’s something that I pick up so much and is missed. This kid had a tick bite when he was a year old and didn’t have a bull’s eye, never got tested or treated. So obviously, I’m checking him for ticks, a tick-borne disease. But that’s one of the things, and it’s not only Lyme disease, Chris. As you know, it’s co-infections. It’s Bartonella, it’s Babesia, and mycoplasma and things. But so many kids, if they get tested for Lyme [disease], they’ll get this one Lyme titer from a general lab that’s not really very good for Lyme. Stats show that can only be maybe 55 percent sensitive, so they get a negative test and you don’t have Lyme. It’s a lousy test anyway, and they haven’t even looked at the co-infections, especially Bartonella when it comes to rage, which is what we call Bartonella rage. So I think it’s so important. The key is that your doctor, whoever they see, considers the possibility of infections. And that can range from strep to mycoplasma, chlamydia, to all the tick-borne infections.

Chris Kresser:  Viral infections.

Kenneth Bock:  And virals like Epstein-Barr [virus] and [cytomegalovirus] (CMV), and all those things. But we do a very thorough infection profiling. We see somebody like I did today, and you have to. So okay, because I always say if they have a tick-borne infection, and if you, we see a lot of people from endemic areas, which means that ticks are known to be there, and these kids are out playing soccer and they kick a ball, it goes into the woods, [and they] go get it. And almost half the people generally, they don’t always get a tick bite and they don’t get the rash. So it’s just important to have it on top of your mind. Okay. And some of these infections are ubiquitous. So, but then (crosstalk 18:17).

Chris Kresser:  Yeah, becoming more common.

Kenneth Bock:  Totally, totally. I mean, Lyme disease. [At] one point, they were saying [it] was 30,000 a year, and then a few years ago, the [Centers for Disease Control and Prevention] (CDC) [recommended], they [said] well, it’s actually 300,000 a year. Now it’s up in the fours, [430,000], [450,000] infections per year. It’s really common. But the other thing [is] anything that causes inflammation has to be considered. And I want to make sure that people know I’m not saying that every psych symptom and disorder has a medical biological underpinning. It’s not true. A girlfriend breaks up with the boyfriend and vice versa, and one of them is really depressed and hopefully not suicidal, but it can be that bad. I mean, that’s a psychological thing. Now, that stress actually causes inflammation. But it’s a psych trigger. The point being is that that is sometimes. Sometimes, a panic disorder is a panic disorder. There’s a past trauma, this or that. Even though a lot of times, those things do cause inflammation. But it’s anything that can contribute to inflammation like allergies, like the kid today. [It] turns out, we tested for allergies, [and] he’s got a milk allergy and eats tons of milk and cheese. Well, that could make a huge difference in this kid’s psyche. Sometimes, milk can cause depression and psych symptoms, and not just bloating, gas, diarrhea, [and] those kinds of things that we think of.

And it’s nutritional imbalances because a lot of the nutrients are involved in the neurotransmitters. So we look at [vitamin] B6, zinc, magnesium, methyl B12, methyl folate, and we even look at the MTHFR gene, which is the gene that helps one convert folic acid to the active methylfolate for the brain. And it’s not always a frank deficiency. Sometimes, it’s just an imbalance. And we have to be aware of that. So we test a lot of more metabolic parameters and functional tests rather than just the static level. And vitamin D is a key, key level. Because for the blood–brain barrier, vitamin D is important as well as for a proper functioning immune system. So all those things and then hormones. We see a lot of kids [who] may have thyroid dysfunction and adrenal dysfunction. And along with adrenal dysfunction, you may see reactive hypoglycemia, which is low blood sugar, and you get the right history where a kid who gets hangry, that whole hangry, where he doesn’t eat frequently then gets really angry and can even rage or, might get shaky, whatever. And it’s discounted; it’s just not looked at. And I just don’t understand, quite frankly, Chris, why sometimes it’s so late.

Chris Kresser:  Yeah, I think another big one is sleep deprivation, which, of course, is inflammatory, affects the gut microbiome, affects hormone levels, everything that we’ve basically been talking about. Kids these days and teens are burning the candle at both ends, especially as you know, when adolescent teen years, they set in, they actually start to need more sleep again. There’s a period of time from eight to 12 where the number of hours of sleep that are required drops a little bit compared to younger years. And then it increases again at the very time when kids are being asked to wake up earlier, go to school early, [and] they’re staying up later because their chronotype is shifting. I’ve seen a lot of kids, teens and stuff who are going to bed at 11, 12 at night because that’s how their chronotype is kind of shifting, and then they’re waking up at 6 or 6:30 in the morning to go to school. I mean, they’re literally two or three hours less, getting two or three hours less sleep than they need. And that, to me, is catastrophic in terms of the consequences.

Kenneth Bock:  And I agree, I think it’s frequent. I really feel teams are in a pickle because school is starting earlier because they want to allow for the team sports and the extracurricular[s]. I get it. But then they’re up, and it’s also, they’re up on social media.

Chris Kresser:  On phones.

Kenneth Bock:  On their phones. And that’s going to keep them from going to sleep. So I agree with you. I mean, I really think that teens are getting bombarded these days. It is not easy being a teen. Much harder than I think it was in our day, much harder.

Chris Kresser:  Absolutely. Yeah, I absolutely feel that way, as well. And then just not to gloss over this too much either is, yes, there are kids who are gluten intolerant, [and] there are kids who are casein intolerant. But even just kids who don’t have those intolerances, if they’re eating mostly flour, sugar, industrial seed oil, which is now 60 percent of the calories that the average American eats, those foods are metab, or the bad bacteria and fungi in our guts just absolutely have a field day with those types of foods. And that in and of itself could drive gut dysbiosis that can cause these kinds of problems. And as you know, over the last 10 years, there’s been a lot of research on this inflammatory cytokine model of depression, for example. It was always, the idea in the past was that depression is an imbalance of brain chemicals, serotonin, neurotransmitters. And now, a lot of the more recent research suggests that it could actually be a gut–brain axis issue, inflammation in the gut. Fire in the gut, fire in the brain, right? How long have we heard that in integrative medicine?

Kenneth Bock:  And that’s why anti-inflammatories work. Listen, there [are] articles, and these don’t have to be natural anti-inflammatories like curcumin and resveratrol, and things. But they can be even celecoxib, which there are articles on, and I use that a lot in the kids. Because unfortunately, [non-steroidal anti-inflammatory drugs] (NSAIDs) can also contribute to a leaky gut. So there’s always a risk, but yet, there are sometimes you add that in, it’s huge. Some of the kids take ibuprofen, and it makes a huge difference.

Chris Kresser:  I think, yeah, it can be interesting, too, just even as a therapeutic trial to see how much of a role inflammation is playing. You take a dose of NSAIDs and if they have a huge response, then that’s a good indicator that inflammation is a primary driver of what’s going on. Even if you then want to find other ways of managing the inflammation later, right?

Kenneth Bock:  I always tell them, because I also use psych meds. And sometimes, they’re so bad you need (inaudible 24:56). I mean, I’m not giving [selective serotonin reuptake inhibitors] (SSRIs) as mood stabilizers. I happen to like the (inaudible 25:01) much better. But sometimes, low-dose Abilify, you need it. I mean, if a kid is so aggressive that a family is worried about it, but I always say, it’s not enough to give a psych med. You always have to be looking for what’s underlying it, but it doesn’t mean that a psych med is not helpful for a while in certain situations.

Tune in to this episode of Revolution Health Radio for a groundbreaking approach to understanding and treating mental health among adolescents and teens, from renowned integrative family physician Dr. Kenneth Bock. #chriskresser #inflammation #mentalhealth #depression

Chris Kresser:  Yeah, I appreciate that you brought that in. And also, before [you] also said that we’re not trying to be too reductionist here and say every single psychological behavioral issue is 100 percent biological, physiological. There are still circumstantial factors that affect our mental health and behavioral health. But I think what you’re saying here is we need to look at the whole picture together, and look for the root causes and try to address those root causes. And yes, if you need to use psych meds as a way of giving relief to the kids and the parents and the families, then sure. But don’t only do that, right? Don’t let that be the starting place, or the stopping place, which is really what it is in the conventional medical establishment. There’s rarely any investigation into what the root causes might be. And my concern there is, the psych meds don’t solve the problem. They help with the symptoms generally, but they’re not actually addressing the cause in most cases, it seems.

Kenneth Bock:  Some of them actually are anti-inflammatory, Chris. So there actually is an inflammatory component of some of the psych meds. But the same holds true in psychotherapy. I mean, I like all my kids to be going through psychotherapy because you have to help them cope, you have [cognitive behavioral therapy] (CBT), you have to teach them things. But all this, and I think you saw, all the psychotherapy and all the psych meds in the world [are] not going to help a kid get well, if he’s got an underlying tick-borne infection and autoimmune brain inflammation. It’s just not going to do it.

Chris Kresser:  That’s right. Yeah. Likewise, if, as you’re kind of hinting at, even if there’s a tick-borne illness and infection, you may need to address that and layer on some psychotherapy. Because some of those issues, once they get started, they can become kind of a loop or repetitive patterns of behavior that skillful therapy can be helpful in resolving. So I know a lot of parents, and this is probably not an easy question to answer, but I’m going to ask it [anyway]. A lot of parents are listening to this and probably relating, and seeing, imagining that this is impacting their kids and how do they get help. Obviously, you’re one option. It’s challenging, I think, for a lot of parents, because if they take this kind of information to their local doctor, chances are pretty low that they’re going to be able to get the kind of help that they need, the testing that they need. I think reading your book is a really good start because then they understand the lay of the land. But it’s, I’ll just say, it’s frustrating for me as a clinician who’s been treating these kids for so long, just to not be able to help more people. Because there’s a limit to how many people we can see, right?

Kenneth Bock:  That’s one of the reasons why I wrote the book. (Inaudible 28:26) And because it does, it reaches people all over. [It’s] actually been published in six languages now. So it reaches people all over the world. And yeah, I’m not obviously, people fly to me from all over the world. But obviously, I can’t see everybody. I’m not the only one who does it. People go online, [and] there are PANS and PANDAS organizations, and [there are] support groups, and the parents refer each other to doctors in different places. And the problem is, some are better than others, and some are more thorough than others. And hopefully, the parents have to do their research and things. But I think more and more, I think more and more physicians are (inaudible 29:07). I hear more and more pediatricians who are open to, who may start even giving an antibiotic for a little bit longer than they might for a strep throat, because a lot of times, you have to treat a (inaudible 29:18) for at least 30 days, let’s say. So there’s a little bit more of an opening, and then if it’s behind them, if it’s a [really] complicated case, they refer it. So I think all we can do is hope to educate, and the parents have to do their research. I mean, and obviously, see people. And it does make a difference if their experience, I have to be honest, I see some people [who] have seen certain people come to see me, and they say we’ve done everything. And I look and I say not even, you probably see the same thing, not even close.

Chris Kresser:  Yeah, right.

Kenneth Bock:  Same thing with kids [on] the spectrum. I mean, not even close but. So it is frustrating, but I think more and more, there are more options for parents, and I do think maybe starting with the book I wrote or other books like that, that can give them a lay of the land and give them an understanding of what they may be looking for and what may be going on. Because it makes them also realize that they’re not crazy and their kids [are] maybe not crazy. But there’s actually something going on.

Chris Kresser:  Yeah. Yeah. I think we’ve already touched on some of these points, but I want to summarize it and condense it. What are some of the signs you look for if a kid comes to the clinic complaining of some of these issues [that are] psychological or behavioral issues? What are some of the signs, top signs you look for that would indicate there may be biological or physiological factors? You’ve talked about constipation and gut issues, of course. But what other signs or symptoms are the biggest red flags for you to go looking further?

Kenneth Bock:  I think the one is the timeline, is frequently the abrupt onset from a kid who is really, I get these kids who are top of the heap. I mean, they’re great athletes, they’re really A plus students, [they’ve] got tons of friends. And within a very short time, whether it’s overnight, which it can be, or within a certain period of time, they become demons. They become different kids. They’re crying, they’re aggressive, and they don’t have an obvious psych trigger, like, a boyfriend dropped them, or they’re getting intensely bullied. You always have to think about that. And I always question whether, if they’re very different in school and home, that’s a clue that it may not. I mean, if you’re very good in school and you have only issues at home, that may be the behavioral issues of a teenager, what we call teenageitis. So it’s really those kinds of questions that we have to ask. So the timing of it, what makes it better. Hey, you give a kid, they get sick and then they probably don’t correlate that they deteriorate psychologically. But you give them an antibiotic, and they get better, you can’t always see that. But if it’s kind of a repeated thing or if it’s bad bowel problems, or if they have other symptoms. Do they have a tick bite? Do they live in an endemic area? Are they out there hiking and camping? Those kinds of things for tick-borne things.

But even thyroid. Are they cold when others aren’t? Are they gaining weight and they’re not on a psych med that’s going to cause them to gain weight? Are they constipated? Do they have dry hair and dry skin? And is it related to eating? Do they get worse? Do they somehow have more emotional dysregulation after they eat, which may be a food allergy or sensitivity? Or when they don’t eat, a low blood sugar where they get shaky, or tremulous and hangry and stuff? So, I mean, I think it’s just a matter of, even before the testing. That’s why at the end of every chapter in the book, I put in all these questions that the kind of clues. Because, a lot of times, the whole thing, as you probably know as a clinician, really, I do a physical on everybody, and that certainly can help. But that doesn’t take that long. It’s the history that really points you; 95 percent of the time, you know what’s happening after you’ve done a really, really good history. And the labs confirm it. So, I always say I treat kids, I don’t treat the lab. The labs confirm. And then, obviously, I can’t tell them what their zinc level is, or their vitamin D level is or which tick-borne [disease] they have. Although I have my thoughts, and hopefully, after 40 years, I’m right some of the time.

Chris Kresser:  Got some educated guesses there.

Kenneth Bock:  Yeah, they call them educated guesses (inaudible 33:43).

Chris Kresser:  Let’s talk a little bit about labs because this is a common scenario, I’m sure you’ve seen over and over when a parent comes in and says, we’ve had the labs done, [and] they’re all normal. And it is typical, in my experience with a lot of these kids, that basic labs might be normal. So if they have just a very rudimentary blood workup where their fasting glucose and just maybe a comprehensive metabolic panel (CMP), and some of the basic tests that a primary care physician might order, all come back normal, or at least within the standard reference ranges that are used. But those are not the labs that you’re talking about I imagine. You’re talking about probably the functional integrative medicine labs or more detailed blood work that’s looking at inflammatory cytokines or markers of inflammation, more specific nutrient analysis, etc. So can you talk a little bit about the labs that you find most helpful?

Kenneth Bock:  You need to see a [complete blood count] (CBC) and a chem profile because you need to get a look at liver and kidney, because certainly, if you’re going to use any medicines, you have to make sure those things are okay. And with tick-borne, they can be abnormal. You can have a low white count, you can have platelets affected, liver function affected. So you have to look at that stuff. Then we do an in-depth tick-borne evaluation. I wouldn’t say on everybody, but on anybody that I think it may be playing a role, and it’s certainly a lot of the kids. So that’s much more comprehensive. It doesn’t only look at Lyme [disease], and we send them to labs that really specialize in tick-borne infections. So, the literature really shows the variability of labs, and how the regular labs really, literally for Lyme titers, 55 percent of the time, it picks it up, someone’s 50/50. So, we use much better labs. So that’s those.

And then, you have to remember from the regular labs, you can get strep titers, and you can get mycoplasma and chlamydia, and you can get your viral titers. That all can come from regular labs. And then, the more integrative labs, we will also do food allergies, which again, and depending like this kid had, if they have seasonal allergy, can do inhalers, as well. Those again, can come from regular labs. But if you do food sensitivities, that’s going to have to go to a specialized integrated lab. And you can check zonulin, and markers of intestinal permeability, or hyperpermeability. And we get stool analysis that [is] really looking at the microbiome and looking at absorption. So many of the kids have malabsorption. I mean, it’s not the majority, but certainly, a number of them have malabsorption. So you have to see that so many have dysbiosis. It’s just uncanny. And then we do some kind of a nutritional evaluation. So again, not only just static going to a Labcorp or Quest, and just getting a [vitamin] B1 and [vitamin] B6 level, but getting markers where those you get, you can test enzyme activity, you can test metabolites. And those metabolites, if they’re low or high, can reflect the activity or inactivity of a certain nutrient like [vitamin] B12, or [vitamin] B6, or [vitamin] B1, or zinc, or magnesium. And we do [always] look at minerals and heavy metals. You have to because so many of the kids are magnesium deficient, zinc deficient.

Chris Kresser:  Yeah, lead, mercury, cadmium, and arsenic, more common. Yeah.

Kenneth Bock:  Mercury, for sure. Lead is a biggie. And it’s missed because it’s not looked at. I mean, I have to say, this is what I wrote in 1997. I mean, it goes right back. I said, if you don’t look, you won’t see. And if you [don’t] listen, you won’t hear. And how many, and again, I don’t want to put down pediatricians in any way because they’re doing their best having to see so many kids in a day.

Chris Kresser:  Absolutely.

Kenneth Bock:  But if you say, oh, you eat a healthy diet, American diet, you’re fine. And never look at, maybe some of them are looking at vitamin D now, but not a lot. But they’re not going to ever look at zinc or magnesium or whatever. And so many kids are zinc deficient, or relatively ever, relative zinc insufficiency. And I think that’s a big point that needs to be made. You don’t have to be frankly deficient to need certain nutrients to help you. We all heard of that with Covid, people taking the zinc, vitamin D, and vitamin C is the trio for Covid.

Chris Kresser:  That’s right. We’ve moved, we’re beyond the, we’ve largely conquered scurvy and rickets and beriberi and pellagra. That’s not what we’re talking about here. We’re talking about the optimal level of nutrients that can help us thrive and live [a] long, healthy life. And there’s been so much research over the past two decades that suggests that that level is so much higher than the low end of the RDA or threshold at which an acute deficiency syndrome would take place, like beriberi [or] rickets. And unfortunately, a lot of the lab reference ranges are still configured in such a way that they’re really designed to detect those acute deficiency syndromes and not chronic nutrient shortage. And on the flip side of that, it’s the same with the heavy metals, right? Where historically, our understanding of toxicity was like, what is the level of mercury that will cause an acute mercury poisoning syndrome that would lead someone to be in the hospital? It was not, what’s the level of mercury that could cause a chronic inflammatory response over a longer period of time? And in reality, that’s far more common in the population to have that level of mercury than it is for someone to have mercury poisoning. That’s pretty rare.

Kenneth Bock:  Exactly. And it has to be recognized because the point that I think you just were making is also, it’s individual. So it’s like not everybody needs the same level of nutrients. Because of your physiology and your metabolism and your genetics, you may need more vitamin B1, or vitamin B6, or methyl B12.

Chris Kresser:  Or you have an MTHFR polymorphism and you need more active folate and folic acid. And if you have that polymorphism, you probably don’t detoxify very well. So what might be a perfectly harmless level of cadmium or arsenic for someone else might actually be harmful for that person because they can’t biotransform or detoxify it very well.

Kenneth Bock:  So the point you’re making, I think, and I certainly would totally agree, is this is all intertwined, and that’s why it’s more complicated. It’s in kind of more of a net-like fashion. It’s not linear, and it is dose dependent. So that’s why when people say we’ve done everything and we take this multi and it has everything in it, well, you look at the doses and they’re so low. And for some of these kids who may have dysautonomia, where they get, they stand up and they get either dizzy, lightheaded, get rapid heartbeats and have fatigue and all that stuff, that sometimes a much higher dose of thiamine. Thiamine 1 can be helpful, in addition to some of the other (inaudible 41:30) foods and everything. But the point being is that it’s varied. Your [vitamin] B6 is important for metabolizing some of the neurotransmitters, and some people need much higher doses of B6 and the metabolic P5P and zinc than others. So, I think the key is that it’s not one-size-fits-all. And I think that’s really, if [you] know that and you don’t have one approach to everything, you have a chance of success. If you have your one protocol for everybody, you will hit some. So you will, and there’s no question about it. But you’ll miss so many others. And I think I’ve prided myself for over all these years to be what I call rather eclectic. I’m really, hopefully, I’ve gained knowledge in all these areas over the years, and you do what each kid needs. And sometimes, what that kid needs another doctor might not agree [with], unfortunately. And I tell the parents that. Listen, I think this is what you need. And you’ll have to decide. We always weigh the risk benefits, like longer-term antibiotics and stuff. You’ll always have to weigh them, and you have to protect people from antibiotics, just like from psych meds or anything else. There are nutrients we can give like [N-acetyl cysteine] (NAC) and certain herbs, like milk thistle; you can protect the liver, you can protect the gut with great probiotics and spore-based probiotics and Saccharomyces, all that stuff. So the key is that you just don’t throw things at people without being aware of what they can do, and how you can protect them and how you can deal with any side effects if you see it.

And I think that’s the misunderstanding in medicine. They think that certain things, oh no, that’s a problem when you could really, if you’re, if you test people on antibiotics, if they have tick-borne disease every month looking at liver, kidney, and blood counts, if something pops up, you hold it, you stop it. So the key is to be aware, to be very thorough, and to be very comprehensive. That’s how I think with these kind[s] of situations.

Chris Kresser:  I appreciate that a lot. And I think it’s crucial, especially as we move forward. I think this more individualized medicine is really the future and should have been the past, too. But we didn’t have the wherewithal and the resources to be able to do it. And look, I have a lot of respect for what we’ve been able to accomplish with conventional medicine. We’re excited to be able to regenerate tissue and cure blindness, and pretty incredible technological advances. And then also incredible research. But one of the challenges with the way the research is set up is this double-blind, placebo-controlled trial was really designed as a way of determining drug efficacy and effectiveness. And assuming that the fundamental assumption there is that a treatment will work the same way with everybody, right? That’s baked into the concept of a randomized control trial. And I’ve had this conversation with Mark Hyman a few times, and he was really dealing with a lot at Cleveland Clinic and trying to figure out how to study Functional Medicine, because by definition, it’s a personalized, individualized treatment. So it doesn’t mesh with this concept of a randomized double-blind, placebo-controlled trial with a single intervention that everyone is doing.

So it strikes me like, what you’re talking about, what we’re talking about is much harder, much more complex, much more individualized and much more difficult to study, frankly, in at least the way that we have set things up so far.

Kenneth Bock:  I think part of it is you have to accept that. One of my best friends is a cardiologist, and we love each other. We are so close, [we] can talk about everything, but we just don’t talk about medicine because he just sees it as that. And in cardiology, that’s how it is for them. It’s the (inaudible 45:31). And now calcium score. Interestingly enough, now, they will always, statins and knocking down cholesterol, not to zero but to less than 70. We know cholesterol is important for [the] function of cell membranes.

Chris Kresser:  Cognitive (inaudible 45:44), yeah.

Kenneth Bock:  But now, it’s the calcium scores, which I happen to agree with. And that if you don’t have an elevated calcium score, maybe you don’t need a statin. So their studies, they will make those changes. I think in our field, we have to be more flexible and more open to research that is not maybe as large and double-blind, placebo-controlled, but is enough to let us know that boy, this makes sense. The mechanism makes sense. You see, it’s helping certain people. And the fact that it doesn’t help everybody, from my perspective in autism was this thing called secretin, right? It’s a neurohormone, secretin. Well, there are kids [who] talk when you [give] them secretin. Now you could say, oh, it’s in the imagination. I saw kids have benefited. I had parents swear to me that they did. But they did double-blind studies. And unfortunately, the outliers were just seen as outliers. And they actually, you mesh them all together. So, I think in autism, the field of autism, they’re really trying to do targeted studies where you really, like eating a gluten-free diet. It came from my medical at the University of Rochester, who did this study, and they totally said it didn’t work, when the study was totally faulty. I mean, it really was, and it hurt so many people because they would say, now, you don’t need to be gluten-free because the study shows it doesn’t work. And it was because they excluded anybody with diarrhea. Well, it doesn’t make any sense. I swear that’s what they did.

Chris Kresser:  Let’s just take out the people who are most affected by it.

Kenneth Bock:  So, in any event, you’re right about that. And I think we have to kind of build that into our analogy. We have to use the information we have, and we just have to use that clinical judgment. I was trained in Rochester where clinical judgment was key. So I always tell people, use labs to confirm, but I don’t treat labs, I treat the kids.

Chris Kresser:  Yeah, you treat the kids and you treat the individual kids, which is kind of the point you were just making with the study. That’s another issue with studies. If you come up with a result that’s an average result. But that average result doesn’t take into account the pretty significant individual variation of results that might all average out to a null finding, no change. But it doesn’t acknowledge that 10 kids had incredible change, incredible positive change. And for those kids and those parents, that’s life changing, even though the study might have been a null result and null finding. And that’s why it is so important to treat the individual and not, to respect the research, but understand its limitations in terms of guiding clinical practice.

Kenneth Bock:  And ask the question, which is not asked, what is it about those 10 kids that had them respond? I mean, it’s like, I remember, and I know time’s running out. But I remember I went to a lecture down toward New York City by a neurologist on the drug Namenda. Now I had been using Namenda, memantine, for kids [on] the autism spectrum with pretty decent results in some kids. But it was only one in six, one in seven, which to me is not good. I have so [many] results. So, this guy gave his lecture, and I told him what I was doing and the results, [and] he said, are you kidding? One in six or one in seven in a condition we have nothing for. That’s short of amazing. For me, it wasn’t because I’m used to such better results. But that’s the point. So, if you can help one in six kids with something that’s really got a very low risk, high benefit-to-risk ratio, and yeah, the others you do, a trial doesn’t work, okay. But if you could figure out which ones will respond, and I have over the years kind of tightened that up a bit. But the point being is if you can help kids so much with certain things, and maybe not others, there’s nothing wrong with that. That’s the thing. As long as you’re not hurting them, there is nothing wrong with having some things that may only work in a certain percentage. You know what I’m saying.

Chris Kresser:  Absolutely. And like I said, I think that is the direction more personalized medicine, personalized supplementation based on genetics, genomics, epigenetics, microbiome patterns. We know different microbiome patterns can affect the response to medication and supplements, for that matter. So I think we’re kind of just [in] the early stages of that being a thing. And even [artificial intelligence], and some of the new tools that are becoming available might help us to be able to make sense of that, and then crunch all of the data that we’re starting to collect. But Dr. Bock, thank you so much for being here. Can you tell everyone where they can find more info about your book and just follow your work and stay in touch with you? What’s the best way to do that?

Kenneth Bock:  [To] find the book, they can go to Amazon. And it’s Brain Inflamed: Uncovering the Hidden Causes of Anxiety, Depression, and Other Mood Disorders in Adolescents and Teens. And then my website is BockIntegrative.com. And if they need to get information or call my office, it’s 845-758-0001. And yeah, I mean, basically, there’s a lot on the website. And the book, I really think, when we’re talking about Brain Inflamed, I think for parents, the book was written for parents. So it’s really, I mean, a lot of doctors and potential practitioners have read it. But the book I hope you see was really made to be very understandable. And use it as something you can go to your own physician with. I’m not saying you have to see me. Of course not. You go to your own physician, you bring the book, you bring the questions, you bring the clues, and hopefully, maybe you can start the process.

Chris Kresser:  Yeah, it’s a fantastic resource. And you’ll see the Amazon reviews are exemplary. You see a lot of parents talking about how the light turned on for them after reading the book and feeling again like they’d seen so many different doctors and [were] just so frustrated to not get any validation for what they know is true. And then finally finding some answers or even potential answers. Just knowing that there could be these things that they could investigate and get to the root of what’s going on, that gives parents hope and kids hope. And, to me, that’s the biggest gift for this population because they spent years really feeling hopeless, I think. And just the possibility that they could find a solution to the problem is a really amazing gift.

Kenneth Bock:  Yeah, so that’s that realistic hope. I don’t want people to have false expectations. And when kids are sick [for] a long time, you do the best you can to bring everything back; you don’t know what changes may be ingrained in there and things. But realistic hope to me is so key, and so many of them have been left without any hope at all. And to me, that is, it’s really a tragedy. It’s really a tragedy. Because we go through this whole thing about placebos and hope and psych. Well, we know the mind–body is so important. And then having parents and even the kids, some of the kids I see are hopeless, they are hopeless.

Chris Kresser:  Absolutely.

Kenneth Bock:  It breaks my heart. And hopefully, this is my 40th year. I’m still working because I want to, because I love it. And because I lead change and trajectory of these kids’ lives. And as I said in the book, it’s not only the kids; it’s the families and it’s the parents, the siblings, the uncles, aunts, and grandparents. Because these kids, when they’re really bad, as you know, they can be really, really bad.

Chris Kresser:  Yeah, it can wreak havoc on the family. And it’s worth pointing out as we conclude here that everything we’re talking about applies to adults, too. The population that we focused on in the interview and your population is kids, teens, adults, and kids, adolescents, and teens. But guess what? Every mechanism that we’re talking about here also affects adults with behavioral and psychological conditions.

Kenneth Bock:  100 percent. I treat adults, as well. So, I totally agree. Yeah, I mean, no question. No question.

Chris Kresser:  Well, thank you again, Dr. Bock. It was a great conversation. And thanks, everyone, for listening. Send your questions to ChrisKresser.com/PodcastQuestion.

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