AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset When did you start experiencing your current symptoms? When I got laid off. It’s been getting worse since I can’t find another job. Understanding the cause (client)

I get the impression you have not been satisfied with the explanations that have been given to you previously for your symptoms, is that correct?

What do you think is the cause?

Yeah, I get annoyed when my doctor thinks there is something wrong with me, when I know I am just feeling trapped and bored.

Because I’m at home doing nothing.

Exacerbating factors Is there anything that makes them worse? When I argue with my wife or when we have trouble paying bills. Relieving factors Is there anything that makes them better? Not really. Examination and inspection Mark appears passive and withdrawn. His face is inexpressive, his face is red and he has dark rings under his eyes.

TABLE 10.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone else in your family ever experienced similar symptoms?	I don’t think so.
Obstruction and foreign body
Do you snore during the night and wake up feeling fatigued and unrested? (sleep apnoea)	Yeah. I snore a lot but I think it’s because I drink too much alcohol at night.
Recreational drug use
Are you taking any recreational drugs?

No. The fact I have taken up smoking again is causing friction at home.

Occupational toxins and hazards Could you have been exposed to any potentially toxic chemicals or heavy metals in your previous job? I don’t know. I suppose I could have been but nobody ever said anything about it. Functional disease Did the fatigue begin after losing your job or did you feel it before? (functional origin) Yeah, I used to have loads of energy. Supplements and side effects of medication Are you taking any supplements or medication at the moment? No. Stress and neurological

Have you experienced any associated symptoms to the tiredness such as decreased libido and vague aches and pains along with disturbed sleep? (depression)

Have you experienced other symptoms such as headaches, chest pain, palpitations, dizziness, or feelings of nervous foreboding? (anxiety related)

All of those things.

No chest pains or dizziness, I don’t feel anything much.

Eating habits and energy Tell me about your diet and energy levels. Mark tells you he knows his diet isn’t particularly good at the moment. He is eating a lot of junk food and drinking too much coffee and beer out of boredom. His wife gives him healthy food but he often doesn’t have much appetite for it.

TABLE 10.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Support systems
Do you have a supportive social or family network? Are you aware of the support agencies available to you?	If I really needed help I think the family would do something, but don’t I like to ask anyone for help. Centrelink gave me a list of places, but I haven’t gone to any of them.
Emotional health
Do you think you are depressed?	I don’t think so, I’m just bored and out of work.
Daily activities
Tell me about your daily routine.	Mark tells you he sleeps late, watches TV when he gets up. He might go out to get the paper or shopping with his wife during the day. He is usually in bed by 10 pm.
Stress release
How do you deal with your stress?	Smoking and drinking. I know it’s not good.
Home life
How are things at home right now?	There is a fair bit of tension with my wife. She says she understands, but I think it’s my fault we’re having problems paying the bills. I’m washed up and unemployable at 48. Not a good example to set for the kids.
Action needed to heal
How do you think I can help you? [76]	I don’t know, it was the wife’s idea.
Long-term goals
Do you have any long-term goals?	To be working again.

TABLE 10.4 MARK’ S SIGNS AND SYMPTOMS [1, 6, 7]

Pulse	70 bpm
Blood pressure	125/78
Temperature	36.6°C
Respiratory rate	14 resp/min
Body mass index	29
Waist circumference	97.7 cm
Face	Lack of facial expression, red face, dark rings under the eyes
Urinalysis	No abnormality detected (NAD)

TABLE 10.5 RESULTS OF MEDICAL INVESTIGATIONS [1–5]

TEST/INVESTIGATION	RESULT
Full blood count: To rule out infection, tumour, inflammation, anaemia	All cells appear normal
Epstein-Barr/Ross River virus blood test	Negative for postviral infection
Cholesterol blood test	Within normal range
Thyroid function test	NAD
CRP (C-reactive protein): infection, inflammation, tumour, bacteria	Normal range
Liver function test	NAD
Serum electrolyte blood test	NAD
Serum cortisol blood test	NAD
Toxicology screen	NAD
Lead level	NAD

TABLE 10.6 UNLIKELY DIAGNOSTIC CONSIDERATIONS [1–5, 8–11, 62, 67, 68, 71–73]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Bronchogenic carcinoma	CRP normal
Chronic cardiorespiratory disease	No shortness of breath, hypertension, electrolyte balance normal
RECREATIONAL DRUG USE
*Causal factor:* Liver damage due to alcohol excess	LFT normal
OCCUPATIONAL TOXINS AND HAZARDS
*Causal factor:* Toxins	Toxicology screen clear
*Causal factor:* Lead toxicity	Lead levels within normal range
FUNCTIONAL DISEASE
Electrolyte imbalance (hyponatraemia, hypokalaemia, hypercalcaemia)	Blood test and urinalysis within normal range
DEGENERATION AND DEFICIENCY
Anaemia	Full blood count normal
*Causal factor:* Nutritional deficiency: Mark is pale	No sign of smooth glossy tongue or cheilosis on sides of mouth
*Causal factor:* Organic fatigue: tired, sleep disturbances, no major physical abnormalities	Shorter duration than functional fatigue; Mark’s fatigue does not generally worsen during the day
INFECTION AND INFLAMMATION
*Causal factor:* Current viral infection: glandular fever, Ross River virus	Full blood count normal, no fever
*Causal factor:* Current bacterial infection	Full blood count normal, no fever
Hepatitis	LFT normal, no sign of jaundice
ENDOCRINE/REPRODUCTIVE
Hypothyroidism/hyperthryoidism	Thyroid function test normal
Adrenal insufficiency/Cushing’s syndrome	No low blood pressure or skin pigmentation, serum cortisol within normal range
Diabetes	Urinalysis NAD
AUTOIMMUNE DISEASE
Rheumatoid arthritis/systemic lupus erythematosus	CRP normal
STRESS AND NEUROLOGICAL DISEASE
Causal factor: Psychological depression: adjustment disorder, tiredness, hypersomnia, low mood due to a particular life-changing event or psychological cause	Depression does not continue for more than 2 months; not considered major depression
Physiological depression: postviral infection, depression, fatigue [73]	Blood tests reveal no viral illness such as glandular fever during the past 6 months
Type 2 – minor depression: can be mild or moderate depression	Need to show 2–4 symptoms of depression that have lasted at least 2 weeks; Mark shows more than 4 signs of depression currently

TABLE 10.7 CONFIRMED DIAGNOSIS [1–3, 10, 11]

CONDITION	RATIONALE
Depression: important differential diagnosis to rule out before exploring other possibilities of mental or organic causes for fatigue symptoms	Tiredness that has lasted several months, feelings of guilt, watching excessive amounts of television, excess coffee, alcohol and junk food, feeling like wanting to cry; anxiety began after the trauma of losing his job; fatigue generally improves during the day
Primary origins: primary depression and endogenous depression are associated with conditions that are regarded as primary disorders, i.e. that do not occur secondarily to other medical or psychiatric disorders; these terms refer to depression that is caused by internal chemical and biological factors rather than external stressors	Type 1: major (clinical) depression; has at least five symptoms of depression for more than 2 weeks and causes considerable incapacity with daily activities; can be moderate or severe depression; people often describe symptoms in physical terms

Case analysis

TABLE 10.8 POSSIBLE FURTHER DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [1–5, 8–11, 16, 62–76]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Food intolerance/allergy	Fatigue, depression, recent dietary change since feeling low; Mark may be eating foods he did not previously eat	Need to gain more insight into Mark’s previous and current diet and associated symptoms
OBSTRUCTION AND FOREIGN BODIES
Obstructive sleep apnoea [63]	Daytime naps, tired; sufferers are often obese and Mark’s BMI is 29; can be made worse by drinking alcohol prior to sleeping; Mark wakes up feeling unrefreshed and snores during the night	Do not usually complain of ‘sleepiness’ but rather fatigue generally
FUNCTIONAL DISEASE
Chronic fatigue syndrome: fatigue for at least 6 months that has no physical explanation when there is no diagnosis of psychoses, bipolar affective disorder, eating disorder or organic brain disease [65, 72]	Severe disabling fatigue affects both mental and physical functioning for at least 6 months; Mark is sleeping more, has depression, feelings of guilt, social withdrawal and crying spells	Need to determine whether Mark experiences muscular and mental fatigue for at least 24 hours after exertion before some level of recovery; need to determine if fatigue improves during the day; need to determine if Mark experiences at least two neurological/cognitive manifestations of chronic fatigue syndrome such as impaired concentration and muscle weakness; no significant autonomic, neuroendocrine or immune manifestations of the disorder present for Mark; often due to postviral infection, which Mark has not had
Causal factor: Seasonal affective disorder	Secondary to the winter months; symptoms include increased sleep, tiredness, increased appetite, weight gain	Need to determine if Mark has experienced episodes of depression during the winter months in the past
Causal factor: Physiologic fatigue	Can be caused by depression, caffeine, alcohol, excess sleep, intense emotions; recent diagnostic studies are within normal limits; could be feeling physiologic fatigue concurrently with functional fatigue from depression	Symptoms present for less than 14 days and are not usually associated with changes in self-esteem, social difficulties or overall mood
Causal factor: Functional fatigue	Tiredness that has lasted several months, began after the trauma of losing his job; feeling of fatigue generally improves during the day
STRESS AND NEUROLOGICAL DISEASE
Bipolar disorders: mental illness where individual alternates between manic episodes and major depression [66, 74]	May not think he needs help or there is anything out of balance mentally	Need to determine if there are episodes of manic behaviour that may include restlessness, fast speech, weight loss, difficulty sleeping; not sure if there is any family history of mental illness
Dysthymia: mild depressive illness [70]	Mark could be experiencing ‘double depression’ if he has had intermittent periods of depression in the past; symptoms include tiredness, lack of interest in life, low mood	Lasts intermittently for 2 years or more; need to determine if Mark had episodes of feeling low prior to losing his job
Mixed anxiety and depressive disorder	Depressive disorder often associated with an experience of loss; symptoms of fatigue, apathy or intense sadness; Mark has mentioned a significant incapacity to continue daily activities for work and family	Numerous physical complaints associated with depression such as restlessness, headaches, insomnia, shortness of breath, gut or skin disorders
Posttraumatic stress disorder (PTSD): symptoms often develop within 6 months of the stressful event	Family tension could indicate emotional detachment from his family; Mark’s symptoms developed after he was made redundant; Mark has mentioned anxiety about re-training and finding a new job	Has not mentioned flashbacks to a particular traumatic event such as losing job
Causal factor: Emotional stress	Tired, concerns about job security, financial difficulties, family strain; longer duration than acute organic origin of tiredness	No irritability or shortness of breath reported
Causal factor: Suicidal tendencies	Secondary to anxiety and depression; more common in males over 45 years of age; Mark appears emotionally depressed	Need to determine if Mark has had thoughts of suicide, a history of suicide attempts, long history of alcohol abuse, family history of substance abuse or has experienced any psychotic symptoms

Working diagnosis

Mark and depression

Mark is a 48-year-old man who was laid off work six months ago. Since this time Mark has experienced increased fatigue, sleepiness and a lack of interest in daily activities. Mark has started smoking again and is eating unhealthy food, not exercising, is emotionally detached from his wife and is experiencing feelings of guilt and worthlessness. Mark recently had a series of blood tests that ruled out several organic causes for his current symptoms of depression. His doctor would like him to begin a course of antidepressants but Mark does not believe he is depressed.

Depression is diagnosed when a person has had a shift in their self-esteem and are more self-critical, feel hopeless and helpless, guilty and pessimistic. Other signs of depression include negative physical and cognitive symptoms. Types of depression may be categorised under several terms that include whether the depression is primary, secondary, major, minor, mild, moderate, severe and psychological or physical. Major and minor depression are defined on a rating scale dependent on how many symptoms of depression are present every day for at least two weeks.

Mark’s symptoms have now developed into what appears to be a primary major depression with severe symptoms present for more than two weeks. The clinical definition of major depression involves a prominent and persistent depressed or low mood that interferes with daily functioning almost every day for at least two weeks, and normally includes at least four of the following symptoms:

• depressed mood most of the day nearly every day

• diminished interest or pleasure in everyday activities most of the day nearly every day

• insomnia or hypersomnia nearly every day

• significant change in appetite nearly every day with weight loss or gain

• fatigue or loss of energy nearly every day

• psychomotor agitation or retardation such as restlessness or slower movements

• lack ability to think or concentrate nearly every day

• feelings of worthlessness or guilt nearly every day

• recurrent thoughts of death or suicide.

It can be common for a person not to recognise they actually have major (clinical) depression and may only understand their symptoms from the perspective of physical changes rather than psychological. Although Mark may have initially had reactive depression that was a secondary response to a life event, his symptoms have continued and present as a potential chemical and biological imbalance that is difficult to restore to equilibrium.

General references used in this diagnosis: 1–5, 62, 67–69

TABLE 10.9 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to improve symptoms of depression • Physical therapy suggestions to help improve symptoms of depression • Dietary recommendations to increase intake of essential nutrients for optimal production of serotonin and other neurotransmitters • Dietary recommendations to eliminate foods that may be having an adverse effect on Mark’s mental health • Herbal tonic, tablets or tea with antidepressant, anxiolytic, tonic and adaptogenic action

• Lifestyle recommendations to eliminate unhelpful habits or behaviours and improve general health and fitness

• Dietary recommendations to improve general health and nutrition and avoid consuming food or drinks that may be adversely affecting his mental health

• Herbal tonic, tea or tablets with adaptogenic and tonic actions

• Recommendation for Mark to attend counselling

• Recommendation for Mark to consult a careers advisor

• Prioritising herbal and nutritional supplement recommendations to help with affordability

• Emphasise dietary changes and lifestyle modifications that are more affordable

• Nutritional supplements to improve symptoms of depression

NB: the use of 5-HTP, l-tryptophan or s-adenosylmethionine (SAMe) must be monitored to ensure there are no adverse reactions; if Mark decides to take l-tryptophan, 5-HTP or SAMe in conjunction with the herbal tonic, tea or tablets, the herbal formula should be reformulated due to the potential for interaction between 5-HTP, l-tryptophan and SAMe with St John’s wort

• Nutritional supplements to increase intake of essential nutrients

TABLE 10.10 DECISION TABLE FOR REFERRAL [1–5, 8–11, 16]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Untreated symptoms of major depression as Mark has not chosen to follow his doctor’s advice to take antidepressants • Depressed mood most of the day nearly every day • Diminished interest or pleasure in everyday activities most of the day nearly every day • Hypersomnia nearly every day • Significant change in appetite nearly every day with no weight loss or gain • Fatigue or loss of energy nearly every day • Feelings of worthlessness or guilt nearly every day	• Increased alcohol intake • Taken up smoking again	• Relationship tension with Mark’s wife • Doesn’t feel he can talk to his wife • Low self-esteem • Financial stress; will affect Mark’s ability to afford treatment recommendations • Concerns about employability and retraining options • Unwilling to share the extent of his emotional feelings
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
Nil	• Poor diet resulting in inadequate intake of essential nutrients • Lack of physical activity	• Sleeping during the day because he is ‘bored’ • Watching TV excessively and isolating himself
REFERRAL DECISION	REFERRAL DECISION	REFERRAL DECISION
• Recommendation for mental health assessment and clear information to be provided to Mark regarding choice of taking antidepressants and working collaboratively with a doctor, psychotherapist and counsellor support symptoms of major depression [69]	• Dietary assessment and evaluation to ensure adequate intake of nutrients for nervous system support	• Counselling and mental health assessment [70] • Family counselling

Confirmed diagnosis

Major clinical depression with functional fatigue

Prescribed medication

• Antidepressant medication – previously prescribed. Mark has decided not to take the antidepressant medication at this stage and wants to try natural therapies.

TABLE 10.11 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–5, 7, 10, 11, 16]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Referral for counselling	Emotional assessment and support
Referral for mental illness assessment	If it is felt Mark is in danger of hurting himself or someone else; it is important that other health professionals are also aware a client may have suicidal thoughts and tendencies
IF NECESSARY:
Sleep clinic observation	Sleep apnoea
Anti-nuclear antibody	Autoimmune disorders
Vitamin D [22, 23]	Vitamin D deficiency
Heavy metal toxicity screening: mercury, cadmium, arsenic, nickel, aluminium [8, 9]	Heavy metal toxicity can cause neurological and behavioural changes [24]; lead levels are within normal range, but other heavy metals have not been tested for
Serum test for biotin, folic acid, vitamin B6, B2, B3, B12 and C, calcium, copper, iron, magnesium and potassium	Deficiency can cause depression [8, 9]
Brain scan	Brain tumour

TABLE 10.12 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Continue with lifestyle recommendations to improve symptoms of depression • Continue with physical therapy suggestions to help improve symptoms of depression • Continue with dietary recommendations • Continue with herbal tonic, tablets or tea • Continue with essential nutritional supplements NB: If Mark decides to take prescribed antidepressant medication his herbal formula will need to be reformulated to remove St John’s wort; if he is taking l-tryptophan, 5-HTP or SAMe, they will need to be discontinued if he decides to take the prescribed antidepressant; Mark must be monitored collaboratively with his GP to ensure his treatment program is effective and to adjust the program where necessary

• Continue with lifestyle recommendations to eliminate unhelpful habits or behaviours and improve general health and fitness

• Continue with dietary recommendations to improve general health and nutrition

• Continue with herbal tonic, tea or tablets to support Mark’s stress response

• Continue with essential nutritional supplements; supplement recommendations may be altered depending on the results of serum and/or hair tissue mineral tests for nutrient deficiencies and heavy metal toxicity

• Recommend Mark continues with counselling

• Encourage Mark to continue seeing a career advisor and consider retraining options

• Ensure initial and ongoing treatment recommendations are prioritised to ensure affordability

• Maintain emphasis on dietary changes and lifestyle modifications to help keep the program affordable

Treatment aims

• Identify and address the factors contributing to Mark’s depression [8, 9].

• Balance Mark’s neurotransmitter levels [8, 9, 17, 38].

• Improve Mark’s stress response and adrenal function [9, 17, 49]. Stress-related adrenal dysfunction can result in depression [9, 49].

• Support normal function of Mark’s hypothalamic-pituitary-adrenal axis [9, 17, 49].

• Optimise Mark’s nutritional status. Nutritional deficiencies may contribute towards depression [8, 9, 17, 22, 45, 46].

• Direct Mark to therapies that help the development of a positive mental attitude [8, 47] and skills to improve quality of life [9, 47].

• Improve Mark’s lifestyle to reduce or eliminate factors such as excessive alcohol consumption, smoking, poor diet and lack of physical activity, which may be contributing towards his depression [8, 9, 21, 35, 47].

Lifestyle alterations/considerations

• Refer Mark for counselling utilising cognitive behavioural therapy that aims to help him develop a positive mental attitude, set realistic goals, avoid negative behavioural patterns and find ways to include laughter and humour into his life [8, 9, 17, 47].

• Regular daily exercise is an effective method of treating depression [8, 9, 17, 47]. Aerobic exercise such as brisk walking, running [21] or weight training [9] has been shown to reduce depression [9, 21].

• Stress-management techniques [49], such as relaxation therapy [9, 47] and yoga breathing exercises [47], might be helpful to Mark.

• Encourage Mark to spend time outside in the fresh air and sunshine to get sufficient sun exposure for adequate vitamin D production. Vitamin D deficiency is associated with depression [22, 23].

• Test Mark for heavy metal toxicity and treat if necessary [9, 24].

• Encourage Mark to live a more healthy lifestyle, incorporating healthy eating, reduced alcohol consumption, quitting smoking and daily physical activity [21, 35, 45, 47].

• Encourage Mark to consult with a careers advisor to help him consider his employment and retraining options.

• Encourage Mark to take up an activity that gives him a purpose and has a positive effect on his family. Planting a vegetable garden may help him to feel he is contributing to the family and may facilitate a greater level of involvement and engagement with his children if they are encouraged to work with him in the garden. Eating home grown vegetables will provide significant nutritional benefits.

Dietary suggestions

• Encourage Mark to follow a Mediterranean-style, nutrient-dense, antioxidant-rich whole-food diet that contains plenty of vegetables, whole grains, legumes, nuts and seeds and cold-water fish [9, 45]. Mediterranean diets have a protective role against depression [45].

• Encourage mark to increase consumption of tryptophan-containing foods such as turkey, salmon, bananas, legumes, fish, whole oats, nuts and seeds, soy and dairy products [8, 9, 17, 40]. Also increase dietary intake of tyrosine from dairy foods, nuts and seeds, oats, whole grains, eggs, fish and soy products [25].

• Encourage mark to increase his dietary intake of omega-3 fatty acids [9, 17, 19, 25, 34].

• Encourage mark to significantly reduce or eliminate refined and processed foods, sugar [9, 17, 19, 46], coffee and other stimulants [9, 17].

• Encourage mark to significantly reduce or eliminate alcohol consumption [9, 35, 56].

• Identify and eliminate foods to which Mark is sensitive or allergic [9, 57].

• Encourage Mark to eat a low GI/GL diet. There is evidence of a link between hypoglycaemia or altered glucose metabolism and depression [19, 20].

Physical treatment suggestions

• Mark may benefit from massage therapy [47, 50, 51]. Massage therapy can reduce anxiety and depression [50, 51]. The use of lavender oil during massage therapy may be particularly helpful [25, 41].

• Electroacupuncture may be of benefit to Mark [42].

• Hydrotherapy: 2–3-minute cold (no less than 55°F/12°C) showers twice a day [18, 52, 55], alternating hot and cold showers with 1–2 minute of hot and 15–30 seconds of cold. Repeat 3–4 times twice a day [18, 54]. Neutral bath from ¼ –1 hour daily for several days [53], full body cold mitten friction [53], constitutional hydrotherapy daily or weekly [53]. Dry skin-brushing prior to bath, followed by wet skin-brushing in the bath with a loofah [54].

TABLE 10.13 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
St John’s wort Hypericum perforatum	60 mL	Antidepressant [25, 26, 47]; anxiolytic [25, 26]; inhibits synaptic reuptake of serotonin, noradrenalin and dopamine [25, 26]; upregulates serotonin receptors [25, 26]; clinical trials indicate use in treating mild to moderate depression [25, 26] Caution should be exercised if Mark decides to take the prescribed antidepressant medication, his formula should be reformulated to remove St John’s wort [25, 26]
Siberian ginseng Eleutherococcus senticosus	40 mL	Adaptogenic [25, 28]; tonic [28]; theoretical application in depression is due to the herb’s ability to increase serotonin and noradrenalin [29]; clinical indications include stress [25, 28], fatigue [25, 28] and to increase vitality [28]
Damiana Turnera diffusa	60 mL	Traditionally used in Western herbal medicine as an antidepressant and anxiolytic [27, 28]; particularly beneficial where there is a sexual factor involved [25]
Rhodiola Rhodiola rosea	40 mL	Adaptogenic [31]; tonic [31]; traditionally used to treat fatigue, depression and nervous system disorders [31]; effective in reducing symptoms of depression [32]; effective in reducing symptoms of generalised anxiety disorder [33]
Supply:	200 mL	Dose: 10 mL twice daily

TABLE 10.14 TABLET ALTERNATIVE TO HERBAL LIQUID: MAY IMPROVE COMPLIANCE

HERB	DOSE PER TABLET	RATIONALE
St John’s wort Hypericum perforatum	750 mg	See above
Damiana Turnera diffusa	675 mg	See above
Schisandra Schisandra chinensis	625 mg	Adaptogenic [25, 44]; hepatoprotective [25]; nervine tonic [44]
Skullcap Scutellaria lateriflora	500 mg	Nervine tonic [43]; mild sedative [27, 43]; indicated for use in nervous tension [27]

Dose: 2 tablets twice daily

TABLE 10.15 HERBAL TEA

A less expensive option if Mark has concerns about the cost of the herbal tonic or tablet
HERB	FORMULA	RATIONALE
St John’s wort Hypericum perforatum	2 parts	See above
Damiana Turnera diffusa	1 part	See above
Lavender Lavandula angustifolia	1 part	Antidepressant [27, 28]; anxiolytic [25, 28]; improves sleep [25], mood [25] and concentration [25]
Oats seed Avena sativa	1 part	Antidepressant [27]; nutritive [25]; traditionally used in depressive states and general debility [27]
Vervain Verbena officinalis	1 part	Indicated for use in depression and melancholia [27]

Decoction: 1 cup 4 times daily

TABLE 10.16 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Omega-3 fish oil supplement containing 2000 mg EPA daily [36] An essential and affordable supplement	Effective in treating depression [8, 9, 17, 25, 34]; supplemental EPA provides significant benefits in treating depression [36, 61]
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement containing therapeutic doses of essential micronutrients, particularly B-group vitamins and vitamin D [22, 25, 59, 60] An essential and affordable supplement	Nutritional deficiency can lead to depression [22, 25, 59]; because Mark’s current diet is nutrient poor supplementation is advisable B-group vitamins are essential for serotonin production [17, 25, 40]; vitamin D deficiency is associated with depression [22, 60]; because Mark spends most of his time inside he may not be getting sufficient sun exposure to maintain healthy vitamin D levels
Tryptophan supplement providing 400 mg tryptophan daily in divided doses [40] NB: In Australia doses of tryptophan exceeding 100 mg are included in Schedule 4 of the Standard for the Uniform Scheduling of Drugs and Poisons (SUSDP) and require a medical, dental or veterinary prescription [37] or 5-hydroxytryptophan [5-HTP] 75 mg daily [17] Alternative to herbal treatment; important supplement, but secondary to essential nutritional supplements and dietary recommendations if finances are tight; alternative to herbal formula; the availability and sale of 5-HTP is restricted in many Australian states and territories	Tryptophan deficiency is associated with depression [38, 40]; using contaminated l-tryptophan has been linked to the development of eosinophilia-myalgia syndrome (EMS); caution should be exercised to ensure only high-quality tryptophan products are supplied [9] Immediate serotonin precursor [40]; increases endorphins and catecholamine and is an effective alternative to SSRI medications and tricyclic antidepressants [9]; 5-HTP has a therapeutic use in depression [17, 40];
S-adenosylmethionine (SAMe) 200 mg 3 times daily [40]; an alternative to tryptophan or 5-HTP if difficulties obtaining or prescribing at the recommended dose are experienced; important supplement, but secondary to essential nutritional supplements and dietary recommendations if finances are tight; alternative to herbal treatment	Effective for mild to moderately severe depression [17, 47]; therapeutic use in depression [17, 40, 47]
Magnesium 800 mg elemental magnesium daily in divided doses [37, 40]; important supplement, but secondary to essential nutritional supplements and dietary recommendations if finances are tight	Supplemental magnesium is an effective treatment for depression [25, 37, 39]; magnesium deficiency may be a causative factor in the development of depression [25, 37, 40]

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Migraine

Case history

Lexi O’Mara, 25, has come to the clinic for help with headaches. Lexi works as a tour guide leading tours around the city and into country areas as well. Lexi’s job involves long hours and she sometimes spends weeks away from home. She likes her job, although not quite as much as she did when she first started working as a tour guide four years ago. The company she is working for was sold about a year ago and the new owners require her to do much more paperwork than she used to. Right now her focus isn’t on the job as much as it usually is because she is planning her wedding, which is only three months away.

Lexi started getting bad headaches about six months ago, and recently she seems to have a very bad one about every three weeks. Before then she never really got headaches, at least not such bad headaches. When they come, they last for a couple of days usually starting in the afternoon at the end of a busy day or at the end of a particularly long or stressful tour. Lexi has not been to see her GP as she does not want to take painkillers if possible but rather treat the cause with natural therapies. Lexi tells you her sister sometimes gets migraines and gave Lexi some of her prescribed Panadeine Forte to try to ease her headaches. It did help but she would rather not take them long term.

The pain develops rapidly and starts behind and above her right eye and then radiates into her temple. Before the pain comes on Lexi can experience a temporary loss of vision in her eye and have a series of flashes and spots in her vision. The pain is then usually an intense throbbing pain that intensifies until she needs to avoid noise and light and lie down in a darkened room. Lexi tells you that once she falls asleep the pain seems to go away and she usually wakes up without a headache, although she usually feels washed out for a couple of days afterwards. Sometimes she feels nauseous and vomits when she has a headache, although she has never noticed a particular food or drink making her nauseous and causing the headache.

When you ask Lexi about her general health you discover that she has been having problems with constipation recently. Lexi drinks lots of coffee and tea and knows she should drink more water. Lexi says she tries to eat well but has to eat what is available when she is on tour. She loves red wine, chocolate and cheese and her comfort food is Vegemite on hot buttered toast.

Lexi tells you she is not sure how much longer she wants to work as a tour guide, particularly doing tours that take her away from home. She isn’t sure what she would like to do instead but is thinking that maybe she will try for a baby soon and be a mum for a few years. Lexi has been taking the oral contraceptive pill for about three years and sometimes skips her bleed when she is doing a country tour because it is much easier if she doesn’t have to deal with a bleed when she is travelling. Before taking the contraceptive pill Lexi had a regular cycle and didn’t have any problems with PMS or pain.

Lexi is very excited about her forthcoming wedding. She is having a traditional church wedding with 130 guests. She sometimes gets quite stressed and anxious about it because there is still so much to do and travelling away makes it more difficult for her to organise things. She is finding it a bit difficult to juggle her time between doing the paperwork, preparing for her tours and organising the wedding. Lexi tells you she doesn’t want to sound like she is complaining, it’s just that there’s so much to do at the moment. She tries not to burden her parents or fiancé since they already have enough to do so she tends to keep things to herself.

TABLE 10.17 COMPLAINT [1–9, 57, 63, 65]

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Headaches

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Exacerbating factors

Do you know what makes the headaches worse after they come on

I think stress is probably the main trigger, but they do get worse with light and noise. Relieving factors What makes them better? Dark, quiet, rest and painkillers.

TABLE 10.18 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Does anyone else in your family have problems with headaches?	My sister gets headaches, but not as bad as mine.
Allergies and irritants
Do you ever notice your headaches are any worse after eating chocolate, cheese, Vegemite on toast, bananas or drink red wine? (amine intolerance)	I am not sure, but I would not be surprised if it is linked somehow.
Cancer and heart disease
Have you experienced any changes in smell or taste recently? (brain tumour)	No, not really, sometimes I lose my appetite but that is not related to not being able to taste things.
Recreational drug use
How much alcohol do you usually consume in a week? Do you smoke? Do you take any other recreational drugs?

I’m not a big drinker. I sometimes have a glass of red wine with dinner to help me wind down, but not every day. I usually have 3–4 glasses on the weekend if I go out.

No, I never have.

No.

Functional disease

Do your symptoms of headache improve when you are not working?

Do you know if you grind your teeth during the night? (muscle contraction headache)

Does your headache come on after exercise, coughing or having sexual intercourse? (exertional headache)

Yes, I did think that, but now that I’m organising my wedding when I’m not working, I notice them coming on any time more frequently.

My fiancé has not mentioned me doing this and I have not had any suggestions from my dentist about this in the past.

I can not find a rhyme or reason for why it comes on yet, so I am not really sure.

Infection and inflammation Is your headache aggravated by bending down? (frontal sinusitis, temporal arteritis) I do tend to want to lie down when I have a headache, but it hurts any way I am, not only if I bend down. Supplements and side effects of medication Are you taking any supplements or medication? The pill. Stress and neurological disease

Do the headaches increase in intensity during the day and lessen in the evening? (tension headache)

Have you noticed any discharge or swelling from your eye when you have a headache? (cluster headache)

Do you ever notice redness in one eye, facial sweating and develop the need to move around when you have the headache? (cluster headache)

No, they can be any time of day.

No, I just cannot stand any bright lights.

No, I need to just lie still and flat when it gets bad, moving would make it worse.

Eating habits and energy Tell me about your diet. Lexi tries to eat a healthy diet, but has to eat whatever is available when she is leading a tour. She knows she should drink more water, and wonders whether this is why she gets constipated at times. Her favourite foods are cheese, chocolate and red wine. Comfort food is Vegemite on hot buttered toast.

TABLE 10.19 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Emotional health
Do you ever feel anxious or depressed?	I have been getting a bit anxious about the wedding. Not about getting married but just about having to organise so many things when I have to go away so much. It can be hard to get it all done.
Stress release
How do you deal with stress?	I might have a glass of red, or maybe some chocolate (all the things I probably should not have!). If I have the time and opportunity I might go for a bike ride or a run.
Occupation
Tell me about your job. What is it about your job that you are not enjoying as much as you used to?	I work as a tour guide taking tours around the city and into the country. I can sometimes be away from home for a couple of weeks at a time. The business was sold last year and I have to do a lot more paperwork now. I really hate all the paperwork.
Action needed to heal
How are you hoping I can help you?	Do you have any natural remedies I can take for my headaches instead of painkillers?
Long-term goals
What do you see yourself doing in five years?	Probably with a couple of children, maybe at home or working part time.

TABLE 10.20 LEXI’S SIGNS AND SYMPTOMS

Pulse	75 bpm
Blood pressure	119/82
Temperature	36.9°C
Respiratory rate	14 resp/min
Body mass index	22
Waist circumference	75.6 cm
Face	Tired looking
Urinalysis	No abnormality detected (NAD)

Results of medical investigations

No medical investigations have been carried out.

TABLE 10.21 UNLIKELY DIAGNOSTIC CONSIDERATIONS [1–6, 10, 11, 57, 63, 64]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Vascular complications: acute aneurysms	Sudden extreme and life-threatening acute presentation; BP history not known; often generalised headache pain or in occiput region
Hypertension: sometimes cause dull headaches	BP in normal range; usually generalised headache pain or in occiput region
Transient ischaemic attack (TIA): often begins with loss of vision in one eye due to emboli travelling through the retinal arteries; can have focal prodromal symptoms similar to a migraine	Headache is unusual in TIAs
Subarachnoid haemorrhage: unilateral red eye, acute headache, photophobia	Usually no visual changes and precipitated by trauma; no altered levels of consciousness
TRAUMA AND PRE-EXISTING ILLNESS
Kidney disease: headache	BP in normal range; often generalised headache pain; urinalysis NAD
INFECTION AND INFLAMMATION
Viral meningitis: headaches	No fever or skin rash; usually chronic rather than acute presentation; check if Lexi’s neck is stiff on flexion and not on extension or rotation (sign of true nuchal rigidity)
Temporal arteritis: unilateral chronic headache	More common in elderly women, would have a low-grade fever, decreased vision
Causal factor: Sinus headache: headache worse on waking in the morning	No upper respiratory symptoms mentioned, no frontal facial pain reported; need to check if the dull ache is aggravated by bending; typically worse in the morning and improves throughout the day
Ethmoid sinusitis: headache and pain in the eye	No nasal discharge, sinus tenderness, upper respiratory tract infection; no blood in nasal discharge
ENDOCRINE/REPRODUCTIVE
Diabetes: migraine headaches can be precipitated by hypoglycaemia	Urinalysis NAD
STRESS AND NEUROLOGICAL DISEASE
Ipsilateral Horner’s syndrome: in some migraine headaches and cluster headaches, lesion of sympathetic nerve to eye	No classic physical signs of drooping of upper eyelid and slight elevation of lower eyelid; constriction of pupil of affected eye with dilatation lag
EATING HABITS AND ENERGY
Dehydration: headaches and constipation	Urinalysis NAD, specific gravity in normal range

Case analysis

TABLE 10.22 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [1–3, 5, 6, 10, 11, 56–64, 68]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
ALLERGIES AND IRRITANTS
Causal factor: Food intolerance amine sensitivity [68]	Chronic headaches; loves drinking red wine, eating chocolate, cheese and Vegemite; usually cause or exacerbate migraine headaches
Causal factor: Environmental allergy	Chronic headaches	No nasal congestion, itchy throat, skin rash
CANCER AND HEART DISEASE
Brain tumour	Intermittent headaches, throbbing headache rather than dull; symptoms of nausea and vomiting can occur; headache that is progressively getting worse; vomiting associated with the headache	Headache worse on waking; usually symptoms of disturbed speech, vision, smell or taste; can have unusual sensations, lack of concentration and paralysis; usually slow regular pulse rate and high blood pressure; often generalised headache pain; headache will be made worse by coughing or bending and will be worse in the morning; headache will disturb sleep rather than be improved by sleep; no fever or seizures; usually more common over the age of 50
Ocular tumour	Localised to one eye	Often midfacial pain presentation of headache; blurred or double vision is more common
TRAUMA AND PRE-EXISTING ILLNESS
Causal factor: Liver disease	High alcohol intake, increased dairy and fatty foods, dull headaches	Pulse is usually low and regular; no jaundice or yellow sclera
OBSTRUCTION AND FOREIGN BODY
Causal factor: Intestinal obstruction e.g. faecal impaction with overflow	Can cause vomiting	Check if Lexi experiences recurrent abdominal pain after eating meals
RECREATIONAL DRUG USE
Causal factor: Substance abuse headaches: oral or inhaled nitrates, MSG, cocaine, cannabis, alcohol	Duration of the headache can be up to 72 hours after taking substance; if a person is prone to migraines, alcohol can give a delayed hangover headache affect	Onset of headache depends on the type of substance
OCCUPATIONAL TOXINS AND HAZARDS
Causal factor: Dental work: leaking amalgam [50], abscess, wisdom teeth	Chronic headaches	Check if Lexi has had any dental work over the past 6 months and if she has fillings
Causal factor: Sick building syndrome	Chronic headache	Headaches are worse after working a few days in a row; no upper respiratory complaints or fatigue reported
FUNCTIONAL DISEASE
Tension headache	Intensity of headaches increases during the day; can present as pain occurring at the end of a busy work day or work period, emotional and stressful time, not enjoying work as much as she used to; usually due to psychogenic cause; more common in females and begins in the second decade; can have tension type headache and migraine headaches together	Often associated with occipital (base of the head) and can occur on waking in chronic tension headaches; tension headaches can lessen during the evening without needing to sleep, then develop again in the morning; this pattern can persist all day for several days in a row and for months; usually bilateral dull pressing pain rather than throbbing and persistent in intensity that builds up gradually; no prodromes or nausea associated and does not prevent daily activity; family history of headaches is not significant to diagnosis
Glaucoma	Pain in one eye, headaches	Usually older age group; present with a visual halo around objects; headaches more likely to develop in a dark environment rather than be helped by it; will present as a frontal headache
Causal factor: Exertional headache: can last from 5 minutes to 48 hours [67]	Headache	Check if the headache also comes on after exercise, coughing or sexual intercourse
Causal factor: Eye strain	Recurrent headaches; spending a lot of time reading for work and planning her wedding	Usually dull headaches at the base of the head (occiput area) typical of eye strain; headaches are unusual but may generally occur after a few days in a row of using eyes intensively for close vision
Causal factor: Functional constipation	Headache, not drinking enough water, high caffeine intake, not opening up to people about her concerns	Need to check if more than 1 in 4 bowel motions is lumpy and hard, and causes strain, a feeling of incomplete evacuation or blockage; need to check if manual help is needed to facilitate a bowel motion passing; if fewer than 3 evacuations a week
Causal factor: Postural cause: cervical pain/arthritis	Chronic headaches, can cause nausea	Check what mattress and pillow Lexi is using; check if neck stiffness is board-like or still supple on flexion (as opposed to meningitis stiffness); usually occurs in older age groups
Causal factor: TMJ dysfunction	Chronic headaches, can present in temporal region	Dull headache on waking; no pain mentioned specifically in jaw or ear; check if Lexi grinds her teeth during the night
DEGENERATIVE AND DEFICIENCY
Causal factor: Anaemia	Headaches	Usually more generalised headache pain
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION
Causal factor: Oral contraceptive pill	Side effect of migraine headaches, particularly if Lexi is taking a low oestrogen pill
Causal factor: Probable analgesic overuse: occurs when person uses pain relief medication for over 15 days per month for at least 3 months	Headache that is worsening; headaches can become worse after initially beginning to withdraw the medication; Panadeine Forte can cause constipation	Usually headache presents several times in a month, is bilateral, pressing and tight nature of pain, moderate intensity; can only confirm diagnosis without taking medication for 2 months
ENDOCRINE/REPRODUCTIVE
Hypothyroid	Constipation, headaches	No temperature intolerance, skin or hair changes, weight changes reported
STRESS AND NEUROLOGICAL DISEASE
Cluster headaches: migrainous neuralgia is a condition that causes recurrent bouts of excruciating pain that can wake the person at night and is often focused around one eye; not often associated with family history	Alcohol can precipitate the symptoms; can present in the temporal region; pain presents in one eye and radiates to the face or temporal region; can be precipitated by amine foods such as red wine, chocolate, cheese and Vegemite	Commonly occurs in males aged 40–60 years; headache is severe stabbing and burning pain and of short duration and usually lasts 30–180 minutes; presents with a red eye and can have discharge from the eye; can present with nasal congestion, eyelid oedema, facial sweating, restlessness and wants to move around; can have up to 8 attacks a day; can come back every day for 1–2 months; can recur at the same time every year and at the same time every day; early morning onset is typical; can be associated with peptic ulcer disease
Classic migraine (with aura): severe painful headaches; often unilateral and located in the front and temporal regions of the head; migraines last for 2–8 days	Recurrent headaches that can develop in temporal region and be unilateral; family history of headaches; can experience visual disturbances, nausea, vomiting, better for dark room, sleep and reduced noise stress can exacerbate; headaches usually improve upon waking and after sleep; need to stop moving	Investigate Lexi’s symptoms of visual flashes and spots; tingling and numbness in limbs is often associated
Common migraine (without aura)	No prodromal symptoms, may experience vague fatigue or nausea and vomiting before migraine; family history of headaches; can have tension-type headache and migraine headaches together	Not always unilateral headache pain; presents more like a bilateral tension headache; can get fevers, chills, diarrhoea and skin rash; can have motion sickness
Neurologic disease: multiple sclerosis (MS)	More common in women; visual disturbance prior to MS usually unilateral and caused by optic neuritis	Need to establish if Lexi experiences double vision; usually advanced stages of MS; no significant trauma or injury mentioned in health history so far; need to define if visual disturbance comes and goes
Epilepsy	Sensory epilepsy (partial seizures) can present with similar symptoms to a migraine headache	Often there is tingling and weakness felt in limbs
Causal factor: Stress	Preparing for her wedding and keeping up with work responsibilities
Causal factor: Anxiety	Headaches and increased stress in her lifestyle	Lexi has not reported lack of sleep, palpitations, tight chest, difficulty breathing, loss of appetite, fast talking
EATING HABITS AND ENERGY
Causal factor: Fasting	Preparing for her wedding may have inspired a dietary and fasting program that can precipitate migraine headaches	Need to ask if she has been dieting or fasting
Causal factor: Caffeine overload	Having excess tea and coffee and chocolate

TABLE 10.23 DECISION TABLE FOR REFERRAL [1–3, 6, 10–12]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Lexi experiences a chronic and reoccurring headache • Headache with nausea and vomiting and eye pain • Headache can persist for more than 24 hours • Does not want to get medical guidance in case she is prescribed medication she does not want to take

• Possible dehydration due to lack of water

• Taking sister’s prescribed analgesic medication without medical guidance and possibly creating more symptoms if not dosed correctly

Nil ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE Nil

• Excessive caffeine intake

• Constipation

• Oral contraceptive pill may be contributing to symptoms

• Stress with juggling work and organising her wedding

• Not as happy in her job as she used to be

REFERRAL DECISION REFERRAL DECISION REFERRAL DECISION

• Medical opinion for what is causing the headaches and education on the orthodox approach to treating them so Lexi can make a treatment/management decision from ‘informed consent’ [66]

• Lexi needs dietary guidance and cooking/eating/drinking alternatives

• Determine whether the oral contraceptive pill is triggering or aggravating Lexi’s migraines and recommend alternative contraception methods if necessary [16, 17, 20]

• Emotional and career counselling and/or life coaching may help Lexi with time management and to manage personal and work pressures better

TABLE 10.24 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–3, 5, 6, 10, 11, 13, 57, 63, 64]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Eye tests: visual	Looking through a pinhole will improve vision if caused by refractive error and shows that retinal function is good
Snellen chart	Visual acuity
Relative afferent pupillary defect (RAPD)	RAPD positive in optic nerve disease, chronic glaucoma and retinal damage
Neurological assessment	Assess speech, language, facial expression, neck stiffness, orientation, memory, judgement and reasoning, cranial nerves, motor function (reflexes and tone), coordination, sensory function of skin, joints and temperature feeling, general observation of mood and behaviour
Musculoskeletal assessment	Eyes, neck movement or deformity, joint movement/pain or swelling, muscle wasting or weakness, gait abnormalities, structure of spine and movement, general posture
Abdominal examination: inspection, auscultation, palpation, percussion	Intestinal obstruction
Full blood count	Anaemia, infection
Differential white blood cell count IgE (eosinophils antibody blood test)	Diagnosis for allergic triggers
ESR/CRP	Temporal arteritis/tumour/infection/inflammation
Liver function test	Alcohol and recreational drug abuse
Blood lipids	Carotid atherosclerosis, cardiovascular risk, blood cholesterol
Urea, creatine and electrolytes blood test	This will show in renal abnormalities and diabetes
Fasting blood glucose test	Can differentiate between diabetes, impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT)
Headache diary	Monitor pattern and precipitating factors for headaches
Diet diary	Monitor food intake and possible triggers for headaches
Skin prick testing	Test for specific extrinsic allergies
IF NECESSARY:
Thyroid function test	Hypothyroid
Abdominal x-ray	Constipation
Brain CT scan or MRI [64]	To confirm or rule out brain tumour/lesion/TIA, sinusitis
EEG (electroencephalogram)	Shows evidence of abnormal seizure activity to confirm epilepsy
Arteriograms	Vascular abnormalities
TMJ/cervical spine radiograph	Cervical damage and musculoskeletal reason for migraine
Teeth x-ray	Abscess, wisdom teeth
Lumbar puncture	Subarachnoid haemorrhage, bacterial encephalitis, meningitis

Confirmed diagnosis

Lexi and migraine

Lexi is hoping complementary therapies can assist with recurrent headaches that began six months ago. Organising her forthcoming wedding has taken up a significant amount of her time and attention in addition to her job as a tour guide, which sometimes requires her to travel away from home. Since the ownership of her workplace changed hands, Lexi is not enjoying her job as much as she used to and she has been forced to do more paperwork. Lexi is on the oral contraceptive pill, is feeling more stressed than usual, loves eating chocolate, cheese, Vegemite and drinking red wine, coffee and tea and feels she is not drinking enough water. Over the past six months she has experienced episodes of severe headaches that begin with visual disturbance, pain in one eye and become so intense that only sleep in a dark room can alleviate the pain.

Confirming a diagnosis of headache pain can be a very difficult challenge and it is important that Lexi was referred for medical assessment because her headache pain is severe, associated with vomiting and nausea and can be disabling.

Lexi has been diagnosed with classic migraine headaches and defining features include prodromal symptoms that are usually visual where flashes, jagged lines and patches of light occur and sometimes blindness in one eye is experienced. Tingling, numbness or weakness on one side of the body may also occur. The person often feels nauseated. This prodromal feeling can last from 15 to 60 minutes and then the headache follows. The pain often begins in one spot and then radiates all over the head. The climax of the headache may bring on vomiting and the person needs to lie down in a dark room with no noise. Sleep is usually the only thing that alleviates the pain. The migraine headache will be aggravated by physical activity such as walking.

The cause of the headache is not completely understood but it is believed that the throbbing nature of a migraine headache is due to vasodilatation of blood vessels, with stimulation of nerve endings. Migraines often begin before the age of 20 and genetic factors play a role [69].

Migraines can return at regular intervals but usually have no specific pattern; however, they may present as episodes of pain on the weekend after a busy week. Migraines can be precipitated by vasoactive amine foods in the diet and with increased intake of caffeine. They may also be associated with the menstrual cycle for women and can increase in severity when taking the oral contraceptive pill. Other factors that can precipitate migraines include intense emotions, stress, hypoglycaemia, glare and exertion. Migraines can last up to six hours and occur once a week or less frequently. Often people who experience migraines will also experience tension-type headaches. This can confuse the diagnosis as the two often have the same pathophysiological process [2] but will be treated differently once diagnosed. Family history is a strong indicator for the final diagnosis of migraine headache.

General references used in this diagnosis: 1–3, 6, 10, 11, 56, 59–61, 63

Prescribed medication

• Ibuprofen with codeine [59]

TABLE 10.25 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to avoid environmental or chemical triggers • Dietary recommendations to identify and avoid triggers • Physical treatment suggestions to reduce frequency and severity of migraines • Herbal tea, tonic or tablets with analgesic and migraine-preventative action • Nutritional supplement recommendations to prevent migraine or reduce its frequency

• Dietary recommendations to reduce inflammation and platelet aggregation

• Dietary recommendations to consume important nutrients for migraine prevention

• Dietary recommendations to maintain blood-sugar balance

• Herbal tea, tonic or tablets to reduce inflammation, vasospasm and platelet aggregation

• Herbal tea, tonic or tablets to support digestive function and detoxification

• Herbal tonic or tablets with neurotransmitter modulating activity

• Nutritional supplements to correct deficiencies that may be contributing to migraines

• L-tryptophan or 5-HTP to support serotonin levels

• Lifestyle recommendations to manage stress

• Physical treatment recommendations to manage and reduce stress

• Herbal tea, tonic or tablets with adaptogenic, anxiolytic and sedative action to support Lexi’s nervous system and stress response

• Recommendation for Lexi to express her anxiety and ask for help from her family and fiancé

Treatment aims

• Reduce frequency and severity of migraines [25].

• Restore Lexi’s biochemical homoeostasis and optimise neurotransmitter production [15–17].

• Dampen inflammatory mediators [15–17].

• Decrease platelet aggregation, prevent the release of vasoactive neurotransmitters and reduce vasospasm [15, 17, 39].

• Identify and eliminate dietary and environmental triggers [14, 15, 17, 39].

• Improve Lexi’s digestive function [17, 19, 52], correct intestinal dysbiosis [17–19] and reduce toxic overload [17, 19].

• Identify and correct nutritional deficiencies that may be contributing to the problem [17, 39, 51, 52].

• Improve Lexi’s stress response and stress management [14, 15, 17, 25].

• Ensure Lexi’s blood-sugar levels remain stable. Missing meals and hypoglycaemia may be contributing to her migraines [16, 17, 21].

Lifestyle alterations/considerations

• Stress-management techniques, such as meditation, yoga and relaxation techniques, can help reduce Lexi’s stress [23] and may therefore reduce her migraines [14, 15, 17, 25].

• Thermal biofeedback therapy may be helpful [17, 25].

• Encourage Lexi to exercise regularly to help with stress management and to reduce her anxiety levels [23, 26].

• Encourage Lexi to express her anxieties to her parents and fiancé and seek their help with the wedding arrangements to reduce her stress levels.

• Discuss alternative contraception methods with Lexi. The oral contraceptive pill may be contributing to her migraines [16, 17, 20].

• Encourage Lexi to try to identify and avoid exposure to environmental triggers [16, 25].

• Lexi may benefit from a detoxification program to reduce toxic overload resulting from metabolic waste, food allergy or intolerance reactions and intestinal dysbiosis [17–19].

Dietary suggestions

• Identify food allergies and sensitivities and eliminate those foods [14, 15, 17, 39]. A food diary may help Lexi identify foods that are triggering her migraines. The use of withdrawal and challenge testing may help confirm which foods are migraine triggers. A four-day rotation diet should be used until Lexi has been symptom-free for six months [17].

• Eliminate foods containing vasoactive amines such as red wine, chocolate, aged cheese, yoghurt, Vegemite, citrus, overripe bananas, avocado, red plums, tomatoes and shellfish [15, 17, 39]. Lexi may also need to avoid foods that are fermented during processing such as beer, meat extracts and chicken livers [15].

• Encourage Lexi to increase her water intake and eliminate tea, coffee, cola drinks and alcohol [17].

• Encourage Lexi to reduce her consumption of arachidonic acid from animal fats and fatty foods [17, 41, 53] and increase consumption of omega-3 fatty acids [15, 17, 41, 53].

• Encourage Lexi to increase consumption of nutrient and antioxidant-rich whole foods that are not migraine triggers. Increasing dietary fibre will help improve bowel function and detoxification [17, 55]. Foods high in magnesium and B vitamins will help prevent and reduce symptoms [15, 17, 39, 41].

• Encourage Lexi to eat smaller regular meals of low GI/GL foods to help keep her blood glucose levels stable [16, 17, 21].

• Encourage Lexi to eat ginger, onions, garlic and other foods that can reduce excessive platelet aggregation [16, 17].

Physical treatment suggestions

• Lexi may benefit from acupuncture to help with stress management [23, 24] and prevention of migraine [17, 22, 25, 39].

• Transcutaneous electrical nerve stimulation (TENS) therapy may be beneficial to treat migraine symptoms [17].

• Massage can reduce frequency and severity of migraine symptoms [27]. Including aromatherapy oils in the massage can help reduce Lexi’s stress levels [28].

• Topical application of a 10 per cent solution lavender and peppermint essential oils to Lexi’s temples and occipital region at the onset of symptoms may be helpful [29, 44].

• Hydrotherapy: as soon as headache begins place the head under cold water or pour cold water over it for three minutes, making sure the nostrils keep out of the water to breathe [45].

• Lexi may find that plunging her feet into very hot water at the first signs of a migraine may help reduce the severity or possibly abort it [46]. This is because the heat of the water dilates blood vessels in the feet and causes more blood to flow to that part of the body, theoretically drawing it away from the head [47]. This is a traditional remedy that has been found helpful by some migraine sufferers. Can add 1 tbsp of mustard powder to a hot foot bath for 20 minutes, while placing an ice pack on the back of the neck and a cold compress on the forehead (changing it every three minutes) [45, 46].

• Neutral body bath [48] or 15-minute hot sitz bath (or half bath) finishing off with cold water over the feet and laying down for 20 minutes [45, 49].

• Alternating hot and cold contrast leg douche shower and cold arm shower prior to a head message can be very beneficial in drawing heat away and helping fatigue [45, 49].

TABLE 10.26 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
Feverfew Tanacetum parthenium 1:5 fluid extract	30 mL	Anti-inflammatory [29, 30]; analgesic [29, 30]; inhibits platelet aggregation [29, 30]; decreases vascular smooth muscle spasm [29, 30]; prevents migraine headache [29, 30, 37]
Schisandra Schisandra chinensis	55 mL	Anti-inflammatory [29]; adaptogenic [29, 34]; nervine tonic [34]; improves detoxifying capacity of the liver [29, 34]; PAF antagonist [29]
Ginkgo Ginkgo biloba 2:1 fluid extract	40 mL	Anti-inflammatory [29, 30]; antioxidant [29, 30, 38]; inhibits vasospasm [30]; modulates neurotransmitters and receptors [29, 38]; anti-PAF properties [30, 38]
Ginger Zingiber officinale	15 mL	Anti-inflammatory [29, 30]; antiplatelet [29, 30]; analgesic [29]; antiemetic [29, 30]; can prevent and treat migraine [29]
Skullcap Scutellaria lateriflora	30 mL	Nervine tonic [31, 33]; mild sedative [31, 33]; spasmolytic [33]; traditional indications for use include nervous tension and anxiety [31, 33]
Dandelion root Taraxacum officinale	30 mL	Choleretic [29, 33]; mild laxative [31, 33]; anti-inflammatory [29]; antioxidant [29]
Supply:	200 mL	Dose: 5 mL 3 times daily

TABLE 10.27 TABLET ALTERNATIVES TO HERBAL LIQUID (IF THERE ARE COMPLIANCE PROBLEMS)

HERB	DOSE PER TABLET	RATIONALE
Feverfew Tanacetum parthenium	150 mg	See above
Dose: 1 tablet twice daily
HERB	DOSE PER TABLET	RATIONALE
Brahmi Bacopa monnieri	1200 mg	Nervine tonic [34]; mild sedative [34]; anti-inflammatory [34]
Ginkgo Ginkgo biloba	1500 mg	See above
Rosemary leaf Rosmarinus officinalis	250 mg	Anti-inflammatory [29]; traditionally used for migraine headaches [29, 31, 33]; improves oestrogen metabolism [29, 36]
Dose: 1 tablet 3 times daily

TABLE 10.28 HERBAL TEA

To replace tea and coffee
HERB	FORMULA	RATIONALE
Lavender Lavandula angustifolia	2 parts	Anxiolytic [29, 33]; sedative [29]; traditionally combined with valerian in migraine headache [31]
Lemon balm Melissa officinalis	2 parts	Anxiolytic [29]; sedative [29, 30]; analgesic [29]; anti-inflammatory [29]
Rosemary leaf Rosmarinus officinalis	½ part	See above
Valerian root Valeriana officinalis	2 parts	Anxiolytic [29, 30]; mild sedative [30]; smooth muscle relaxant [29, 30]; traditionally combined with lavender for migraine headache [31]
Infusion: 1 tsp per cup – 1 cup 3 times daily

TABLE 10.29 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Magnesium citrate supplement providing 600 mg elemental magnesium daily [15, 29]	Migraine sufferers have lower intracellular magnesium levels [29, 40]; low magnesium levels are linked to migraine headaches [17, 29]; beneficial for migraine prevention [17, 29, 35, 39–41]
B vitamin supplement providing a daily dose of 75 mg B6 [17] and 400 mg B2 [14, 17] combined with a B-vitamin complex [17]	Supplementation with vitamins B6 and B2 can be effective in preventing migraine [15, 17]
Omega-3 fish oil capsules 5 × 1000 mg capsules 3 times daily providing a daily dose of 2.7 g EPA and 1.8 g DHA [15]	Anti-inflammatory [15, 29, 32]; antiplatelet [17, 29, 32]; omega-3 fatty acids have anti-vasopressor effects [41] and supplementation can reduce migraine frequency, duration and severity [15, 17, 41]
L-tryptophan 500 mg every 6 hours [15, 39] NB: In Australia doses of tryptophan exceeding 100 mg are included in Schedule 4 of the Standard for the Uniform Scheduling of Drugs and Poisons [SUSDP] and require a medical, dental or veterinary prescription [42] or 5-hydroxytryptophan 400 mg daily [17, 43]The availability and sale of 5-HTP is restricted in many Australian states and territories	Serotonin precursor [17, 32]; serotonin disorders are implicated in the pathogenesis of migraine [15, 17, 32]; l-tryptophan supplementation can reduce reduce migraine frequency [15, 39] The use of contaminated l-tryptophan has been linked to the development of eosinophilia-myalgia syndrome (EMS); caution should be exercised to ensure only high-quality tryptophan products are supplied [17] Immediate precursor to serotonin [17, 32]; 400 mg 5-HTP daily is effective in preventing migraine [17, 43]

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Insomnia

Case history

Gordon Fryer, 72, lives in a small coastal town. Gordon and his wife Adele moved there 10 years ago when they retired. Adele passed away two years ago and he has lived alone ever since. Gordon still misses Adele and is not interested in having a relationship with anyone else.

Gordon is visiting his son’s family in the city at the moment and his daughter-in-law has nagged him into coming to the clinic. She has told him you can give him something natural to help him sleep better. Gordon has had problems sleeping since Adele passed away, and some nights he doesn’t fall asleep until 2 am. When he does finally fall asleep his sleep is light and he wakes frequently, which makes him very tired the next day. When he is at home Gordon can take an afternoon nap to catch up on his sleep; however, at the moment the noise and activity in his son and daughter-in-law’s house is preventing him from doing so. Consequently he is exhausted and has become impatient and irritable with the grandchildren.

Gordon tells you that when is lying awake in the night he often feels very lonely, although when he is up and moving around during the day he doesn’t experience the loneliness in such a profound way as he does during the night. He is feeling very frustrated with his inability to get a good night’s sleep.

Gordon loves to fish and freshly caught fish has been a staple of his diet since he retired to the coast. He usually has a bowl of porridge or cereal and a cup of coffee for breakfast and drinks six to eight cups of tea during the day. He relaxes in the evenings with a couple of beers. Gordon still tends Adele’s vegetable patch and grows most of the vegetables he eats. He feels close to Adele when he is working in the vegetable patch, so consequently the vegetables are very well tended! Gordon’s appetite is not what it used to be and he often prefers to have a light meal such as soup or salad for dinner rather than a larger meal.

Gordon has tried reading books, drinking warm milk and having a warm bath before bed. He doesn’t want to take the medication his doctor has offered and is open to any suggestions you can come up with.

TABLE 10.30 COMPLAINT [1–6, 61]

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Insomnia

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset

When did you first start having problems sleeping?

Did you ever experienced sleep difficulties before Adele passed away?

Two years ago, after my wife died.

No, I used to sleep really well.

Exacerbating factors Is there anything that makes it worse? If I can’t get an afternoon nap. At the moment I’m staying with my son and daughter-in-law and it’s hard to get a sleep in the afternoon. I know I’m getting to be a grumpy old man around the grandkids, but if I could get more sleep I’d be much better. Relieving factors Is there anything that makes it better? Having a nap in the afternoon. I tried warm milk, reading books and having a bath before bed but none of that made any difference.

TABLE 10.31 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone else in your family had similar problems?	I don’t think so.
Allergies and irritants
Do you ever experience sneezing or nose discharge, or itchy skin that is affecting your sleep patterns? (allergies)	No, not really – I don’t wake up with a blocked nose if that is what you mean.
Recreational drug use
How much alcohol do you usually drink in a week? Do you smoke? Do you take any other drugs?	Usually a couple of beers in the evening. Not for years. No.
Functional disease
Do you generally experience a delay in falling asleep? (initial insomnia, prolonged latency, common in anxiety, caffeine and alcohol users and elderly)	I find it hard to fall asleep. Sometimes I don’t get to sleep till after 2 am.
Infection and inflammation
Do you usually wake up during the night? (middle insomnia, poor quality sleep, medical conditions such as sleep apnoea, diabetes, prostatism)	When I finally fall asleep I tend to sleep lightly and wake quite often.
Supplements and side effects of medicationAre you taking any supplements or medicines?	No. The doctor gave me a prescription for sleeping pills but I don’t want to use them.
Stress and neurological disease
Do you experience early-morning wakefulness? (late insomnia, depression, malnutrition)	Sometimes, but if I don’t get to sleep until early morning hours, I tend to sleep in to catch up – I think it’s been harder for me to do this staying with my family so it has changed my rhythm of dealing with lack of sleep.
Eating habits and energy
Tell me about your diet.	Gordon’s usual diet consists of plenty of home-grown organic vegetables from the vegetable patch his wife planted. He usually has porridge or cereal and coffee for breakfast and eats a light meal such as soup or salad in the evenings. He drinks 6–8 cups of tea during the course of the day.

TABLE 10.32 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Emotional health
You mentioned you sometimes feel sad. Can you tell me more about that?	It’s only usually at night when I can’t sleep. When I’m up and around during the day it isn’t so bad. Sometimes when I’m lying awake at night I can feel quite lonely and sad; I suppose I think about Adele.
Environmental wellness
Can you tell me about the environment where you live? Are you close to any major traffic routes or industries? Tell me about your sleeping environment.	I live in a very quiet little place out of the way from everything, which is what Adele and I were looking for when we retired. There is the bed and TV in the bedroom. I also have a clock radio and phone.
Daily activities
Can you tell me what you usually do during the day?	I’m up quite early so I start with breakfast and then go into Adele’s garden. I’ll either do some work or just sit and think there. I might go fishing or head into town for a bit of shopping. I’ll usually have a nap after lunch and then read or watch TV until bed.
Action needed to heal
How do you hope I can help you?	My daughter-in-law said you might have something natural I could take that would improve my sleep.

TABLE 10.33 GORDON’S SIGNS AND SYMPTOMS [7, 8]

Pulse	90 bpm
Blood pressure	139/88 sitting
Temperature	36.9°C
Respiratory rate	16 resp/min
Body mass index	20
Waist circumference	72 cm
Face	Pale
Urinalysis	No abnormality detected (NAD)

Results of medical investigations

No medical investigations have been conducted.

TABLE 10.34 UNLIKELY DIAGNOSTIC CONSIDERATIONS [4–6, 9, 70]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Congestive heart failure: insomnia can be a symptom	Blood pressure and pulse within normal range
Hypertension	Blood pressure within normal range
Brain tumour: a growth in the brain may affect the hypothalamic centre, preventing sleep	It is rare for sleep disturbance to be the only associated symptom of neurological disorder
FUNCTIONAL DISEASE
Renal disease: cause of insomnia due to nocturia and the toxic effects of uraemia	Blood pressure, pulse and urinalysis NAD
DEGENERATIVE AND DEFICIENCY
Cirrhosis of the liver: nocturnal delirium with insomnia	No yellow sclera in eyes or jaundice observed
INFECTION AND INFLAMMATION
Acute infection	No fever
Peptic oesophagitis: insomnia can be a symptom	No abdominal pain reported or sensation of heartburn
ENDOCRINE AND REPRODUCTIVE
Hyperthyroid: insomnia a common symptom	Blood pressure and pulse within normal limits, appetite has decreased rather than increased, no common eye symptoms, goitre or muscle wasting suggesting thyroid disease
Addison’s disease: adrenal exhaustion, restlessness, inability to rest and sleep	No sign of skin pigmentation or loss of body hair
Non-insulin dependent diabetes mellitus: restlessness, weight loss, anxiety, lack of sleep	Has not reported any increase in thirst or urination; urinalysis NAD
Prostate disorder: insomnia due to waking up frequently during the night; age related	No nocturia or difficulty with urination reported

Case analysis

TABLE 10.35 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [4–6, 9–11, 57–71]
CONDITIONS AND CAUSES	WHY possible	WHY UNLIKELY
ALLERGIES AND IRRITANTS
*Causal factor:* Food intolerance/allergy	May be eating foods he did not previously eat when Adele was still alive	Need to gain more insight into Gordon’s previous and current diet and associated symptoms
OBSTRUCTION AND FOREIGN BODY
*Causal factor:* Obstructive sleep apnoea: where breathing recurrently stops during sleep for long enough periods of time to cause lack of oxygen to the brain [58, 63, 64]	Daytime naps, tired; can be made worse with drinking alcohol prior to sleeping; more common in males; frequent waking during the night and poor sleep quality is common; may be more pronounced at this time of life now that he is sleeping on his own, as a long-term sleep partner can help him breathe by moving him gently to take a breath again	Do not usually complain of ‘sleepiness’ but rather fatigue generally; need to determine if Gordon does not feel well rested in the morning and if he snores during the night; this is usually worse in individuals who are overweight; not as common to have early morning wakefulness as in depression
RECREATIONAL DRUG USE
*Causal factor:* Alcohol withdrawal	Gordon may drink more alcohol when he is at home than he has been while staying with his son and daughter-in-law; while he is staying in her home, the withdrawal may be causing insomnia; common to have a delay in falling asleep and frequent waking	Need to question Gordon more about his alcohol intake; question him further about stress levels, restlessness, weight loss, missing meals, tachycardia
FUNCTIONAL DISEASE
Insomnia: primary [57, 60]	Difficulty falling asleep, frequent waking during the night	Usually associated with no physical or emotional triggers; Gordon’s insomnia is more likely to be connected to lifestyle change after the death of his wife making it a secondary insomnia
Short-term insomnia: secondary (less than 3 weeks); caused by emotion, excitement, life stress, change, noise, stimulation, pain, grief, anxiety, jet lag, change in working hours	Delayed onset of sleep and frequent waking during the night; staying with family, sleeping in an unfamiliar bed, noise of the grandchildren, recent travel	Gordon’s insomnia may have been aggravated by recent events; however, he has experienced sleep disturbance since his wife passed away 2 years ago
Chronic insomnia: age related	Common to present with difficulty falling asleep, then fitful and light sleep for a short period of time; with age the body can function on as little as 4 hours’ sleep a night; delayed period of going to sleep and poor sleep quality are common	Requires further investigation due to Gordon’s age; often there are associated physical, medical and painful reasons for insomnia in older age groups
Nocturnal asthma	Frequent waking during the night	No breathing difficulty reported
*Causal factor:* Restless leg syndrome	Insomnia; delayed period of going to sleep and poor sleep quality common	Gordon has not reported an uncontrollable urge to move his legs when he wakes during the night
*Causal factor:* Physiologic fatigue: caused by depression, caffeine, alcohol, excess sleep, poor sleep due to an uncomfortable mattress or pillow, being too hot or cold when trying to sleep, hunger during the night, excess exercise and intense emotions	Common to have delay in falling asleep	Symptoms present for less than 14 days and not usually associated with changes in self-esteem, social difficulties or overall mood; diagnostic studies are within normal limits (this needs to be investigated further)
*Causal factor:* Organic fatigue	Tired, sleep disturbances, no major physical abnormalities	Shorter duration than functional fatigue; need to define if the feeling of fatigue worsens during the day
DEGENERATIVE AND DEFICIENCY
Dementia	Poor sleep, restless during the night; age related	No significant signs of neurological disturbance; needs further investigation; unusual for sleep disturbance to be the first sign of dementia
Anaemia: iron or B12 deficiency	Low iron intake or absorption can contribute to insomnia; loss of appetite	Need to gain more insight into Gordon’s previous and current diet and associated symptoms
INFECTION AND INFLAMMATION
Osteoarthritis	Insomnia; delayed period of going to sleep and poor sleep quality are common; age related	No associated aches and pains reported
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION
*Causal factor:* Medication/drug reaction: psychotropics, beta-blockers, bronchodilators, sympathomimetics, diuretics, hypnotics, appetite suppressants, amphetamines, cocaine	Poor sleep quality and delayed onset of sleep are common
*Causal factor:* Sedative misuse	Gordon may have used sleeping tablets in the past and misused the dose, causing withdrawal and insomnia; restless sleep when in a different environment
STRESS AND NEUROLOGICAL DISEASE
*Causal factor:* Adjustment disorder – psychological depression	Insomnia	Aspects of symptoms need to be clarified; usually adjustment disorder depression does not continue for more than 2 months and is not considered major depression; usually a low mood due to a particular life-changing event or psychological cause; need to clarify how depressed Gordon has been feeling since his wife passed away
General anxiety disorder (GAD)	Has been at least 6 months; anxiety disorder is often associated with loss or threat of a loss; weight loss, lack of sleep; feelings of irritation; person often complains of physical symptoms without thinking there may be a mental disorder; delayed period of getting to sleep is common	Ascertain whether Gordon has experienced significant weight loss; if tension and stress have been overwhelming for at least 6 months; often associated with diarrhoea, tight chest, difficulty breathing; less common to experience frequent waking and early-morning wakefulness as in depression
Chronic depression	Chronic insomnia; missing his wife, feeling lonely without her; can be undiagnosed in the elderly population	The fact that Gordon tends to the garden and enjoys fishing are signs that he is active and productive with his daily activities
Type 1 – major (clinical) depression: unipolar affective disorder [62, 68]	Can be moderate or severe depression; people often describe symptoms in physical terms; has insomnia, change in appetite, fatigue; delayed sleep onset, lack of appetite, can be aggravated by certain conditions and situations that provoke depression	Need to determine if at least 5 symptoms of depression have been present for more than 2 weeks have caused considerable incapacity with daily activities; need to determine if Gordon feels worse in the morning and experiences a sense of apprehension; need to define if Gordon experiences early-morning wakefulness (common); frequent awakening during the night (less common); associated symptoms of lack of interest in daily activities, constipation and vague aches and pains are common
Type 2 – minor depression [62, 68]	Can be mild or moderate depression; has insomnia, change in appetite	Need to show 2–4 symptoms of depression that have lasted for at least 2 weeks; early morning waking is common in depression
Dysthymia: mild depressive illness	Could be experiencing ‘double depression’ if Gordon has had intermittent periods of depression in the past; symptoms include tiredness, lack of interest in life, low mood	Lasts intermittently for 2 years or more; need to determine if Gordon has had the tendency to have episodes of feeling low before his wife passed away; early morning waking is common in depression
Mixed anxiety and depressive disorder [62]	Depressive disorder often associated with an experience of loss; symptoms of fatigue, apathy, or intense sadness, insomnia	Can be associated with numerous physical complaints related to depression such as restlessness, headaches, shortness of breath, gut or skin disorders; need to determine if Gordon experiences significant incapacity to continue daily activities
Posttraumatic stress disorder (PTSD): symptoms often develop within 6 months of the stressful event	Symptoms developed after Gordon’s wife passed away	Has not mentioned flashbacks to a particular traumatic event such as the moment his wife died
Causal factor: Extreme worrier/anxiety	May present with difficulty falling asleep, loss of appetite	Need to question Gordon more about his level of worry and if a significant feeling of restlessness is experienced; usually does not present with early-morning wakefulness
Causal factor: Short-term anxiety	Gordon may be more anxious being out of his comfort zone when staying with his son and his son’s family; common to have delay in falling asleep	Often presents with additional symptoms of headache, chest pain, dizziness, palpitations, gastrointestinal upset and nervous temperament
Causal factor: Functional fatigue/depression	Tiredness that has lasted several months and began after the trauma of wife’s death	Need to determine if his feeling of fatigue improves during the day; early morning waking is common in depression
EATING HABITS AND ENERGY
*Causal factor:* Excess caffeine intake	Gordon is consuming excessive amounts of tea; common to have a delay in falling asleep if caffeine is consumed prior to going to sleep; for some individuals having caffeine 6 hours before bed can affect sleep	Not as common to have early-morning wakefulnesss (need to define this symptom)
*Causal factor:* Nutritional imbalance	Insomnia can be worse if there is lack of balance with diet, lack of tryptophan and magnesium-rich foods in the evenings	Need to gain more insight into Gordon’s previous and current diet and associated symptoms; early-morning wakefulness can be caused by malnutrition
*Causal factor:* Jet lag: air travel can affect the hypothalamic region of diencephalon	Insomnia	Did Gordon travel by plane to see his daughter and how far did he travel?
Causal factor: Daytime naps	Although helpful in the short term, if this becomes a continuing routine it can make insomnia worse at night

Working diagnosis

Gordon and insomnia

Gordon is a 72-year-old man who is currently staying with his son and daughter-in-law. Gordon’s daughter-in-law has encouraged him to see a complementary therapist to help him get a good night’s sleep. During the consultation Gordon tells you he lives in a small coastal village and has developed sleep problems since the death of his wife two years ago. Often Gordon experiences difficulty in falling asleep and wakes frequently during the night. Consequently Gordon is feeling tired and irritable, and his fatigue has been exacerbated by in a different environment while on holiday.

Gordon is experiencing insomnia, a common condition defined as ‘difficulty in sleeping’, or having ‘disturbed sleep patterns’ that cause a feeling of having had no sleep at all. Insomnia can be primary (longstanding and with little apparent connection with emotional or physical status) or secondary (to acquired pain, anxiety, drug-alcohol withdrawal, depression). Initial insomnia is difficulty falling asleep and is often associated with an emotional disturbance such as anxiety. Middle insomnia refers to frequent waking during the night and is associated with medical conditions including sleep apnoea. Early morning waking insomnia is where a person wakes several hours before normal waking time and either cannot go back to sleep or goes into a restless sleep. This is common in the elderly but can also be associated with depression. Reversals of sleep rhythm are usually caused by situational and environmental reasons such as work hours changing or jet lag. It is also possible for a disease of the hypothalamic region in the brain to cause significant sleep disturbance.

The consequences of insomnia on daily living are significant and can be life threatening if it affects skills such as driving where being alert is imperative. It is most important to have the cause of insomnia diagnosed and treated rather than allowing unproductive sleep habits to form or dependence on medication to develop.

General references used in this diagnosis: 4, 5, 10, 57, 59–61

TABLE 10.36 DECISION TABLE FOR TREATMENT PRIOR TO REFERRAL

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Lifestyle recommendations to improve sleep hygiene • Dietary recommendations to reduce consumption of stimulants and alcohol • Herbal tea, tonic and tablets to reduce sleep latency and improve sleep maintenance • Supplemental nutrients to help improve sleep • Recommendations for physical therapies to help improve sleep

• Recommendation to exercise daily to improve sleep patterns

• Dietary recommendations to increase intake of nutrients essential for production of serotonin and melatonin

• Dietary recommendations to increase intake of nutrients essential for production of serotonin

• Supplemental nutrients to assist with insomnia may also be helpful to deal with Gordon’s depression

TABLE 10.37 DECISION TABLE FOR REFERRAL [4–6, 11]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Chronically disturbed sleep pattern	• Excessive caffeine intake	• Gordon feels persistent sadness and loneliness after his wife’s death 2 years ago
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
	• Alcohol intake potentially disturbing sleep pattern • Reduced appetite may lead to malnutrition	• Gordon is feeling exhausted and irritable, particularly when spending time with his son’s family
REFERRAL DECISION	REFERRAL DECISION	REFERRAL DECISION
• Medical opinion on secondary medical and psychiatric causes of insomnia	• Dietary assessment required	• Counselling and mental health assessment to rule out severe depression

TABLE 10.38 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [4–6, 8–10, 64, 67, 70]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Full blood count	Rule out infection, tumour, inflammation, anaemia
Electrolyte imbalance	Renal and heart disease
Liver function test	Signs of drug or alcohol abuse
Thyroid function test TSH, T4, T3	TSH (thyroid-stimulating hormone) suppressed in hyperthyroidism; thyroid-specific antibodies, to confirm auto-immune cause of hyperthyroidism (Graves’)
Fasting blood glucose test	Raised levels can indicate diabetes mellitus, Addison’s disease
Counselling/psychiatry consultation: mental health assessment	Bereavement, new lifestyle, early onset of dementia
Nijmegen questionnaire	Hyperventilation syndrome
Sleep diary for one week	Assess patterns of sleep and activities prior to sleep; note the time Gordon goes to bed, how long took to fall asleep, how many times he wakes during the night, the last time of waking before morning, any dreams or nightmares that were experienced; writing down thoughts before bed and when waking is also helpful
Diet diary for one week	Have a more detailed look at what foods Gordon is eating, what times he is eating, how he is preparing the food, amounts of food being ingested
IF NECESSARY:
Sleep centre: polysomnography	Sleep overnight at a sleep centre to be monitored for the cause of the sleep disturbance; rule out sleep apnoea
Capnometer/pulmonary gas exchange during orthostatic tests	Hyperventilation syndrome
Serum cortisol levels	Rule out Addison’s disease
ACTH stimulation test	More definitive for Addison’s disease; given to stimulate adrenal cortisol production
Brain scan	Brain tumour or obstruction causing insomnia
ROUTINE TESTS DUE TO AGE:
Cholesterol blood test	Hypercholesterolaemia
Rectal physical examination	Benign prostate feels smooth, soft, from plum size to orange size; prostatitis, prostatic abscess feels large and boggy; cancerous prostate gland feels hard and irregular nodular enlargement
Prostate-specific antigen (if rectal examination shows possible malignant gland)	Raised in prostatic cancer, benign prostatic hypertrophy, prostatitis

Confirmed diagnosis

Prescribed medication

• Temazepam

• SSRI antidepressant medication if sleep problems are not resolved with short-term use of temazepam [60]

• Gordon has decided to try natural therapies first before taking prescribed medications

TABLE 10.39 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT

CONTEXT

CORE

Treatment for the presenting complaint and symptoms

Treatment for all associated symptoms

Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations

TREATMENT PRIORITY

• Lifestyle and physical therapy recommendations to help improve sleep

• Dietary recommendations to improve sleep quality and quantity

• Herbal tea tonic or tablets with sedative action

NB: Herbal tonic or tablets and tea should be reviewed and reformulated if Gordon decides to take temazepam

• Supplemental nutrients to help improve sleep quality and quantity

• Herbs and supplements should be used until normal sleep pattern has been re-established and then slowly reduced

• The long-term aim is for dietary and lifestyle changes to manage insomnia and depression

NB: Gordon’s treatment program should be reviewed within two weeks and managed collaboratively with his GP to ensure Gordon’s condition is being managed effectively

• Lifestyle recommendations to improve general health and vitality

• Dietary recommendations to reduce consumption of food and drinks that are likely to be aggravating Gordon’s symptoms

• Dietary recommendations to increase consumption of nutrients essential for production of neurotransmitters to help maintain a better sleeping pattern

• Lifestyle recommendations to improve depression

• Recommendation for grief counselling

• Dietary recommendations to improve depression

• Herbal tea, tonic or tablets with antidepressant action

NB: Herbal formula or tablet may need to be reformulated to remove St John’s wort if Gordon decides to take prescribed antidepressants

• Nutritional supplements with antidepressant action

NB: Nutritional supplements should be reviewed if Gordon decides to take prescribed antidepressants

• Massage therapy to help improve depression

• By restoring Gordon’s sleep pattern his depression is likely to be improved [24]

Lifestyle alterations/considerations

• Encourage Gordon to work through his grief and loss. He may find grief counselling helpful as part of a program to help him deal with his depression [14, 22, 23].

• Encourage Gordon to exercise daily. Daily exercise improves sleep [13, 26, 27]. Daily exercise will also help improve his depression [12, 14, 25, 28].

• Encourage Gordon to regularise his bedtime, going to bed and getting up at the same time each day to help strengthen circadian cycling [27].

• Encourage Gordon to not spend excessively long times in bed as this can result in fragmented and shallow sleep [27].

• Encourage Gordon to not try to force sleep. Rather than allowing himself to become tense and frustrated, he should do something else such as reading until he feels tired [27].

• Encourage Gordon to eliminate all sources of light and reduce noise levels in his bedroom [27].

• Encourage Gordon to eliminate the clock from his bedroom [27].

• Encourage Gordon to make sure his bedroom is not excessively warm [27] .

• Encourage Gordon to avoid daytime naps as they reduce nocturnal sleep quality [27].

• Encourage Gordon to ensure his bed is comfortable [27]. If necessary he should get a new one.

Dietary suggestions

• Encourage Gordon to eliminate tea, coffee and other caffeine-containing foods and drinks [12, 14, 27]. Caffeine interferes with sleep latency and sleep maintenance [12, 27]. Caffeine consumption is interfering with Gordon’s sleep even if he doesn’t think it is [27].

• Encourage Gordon to drink a caffeine-free alternative to black tea.

• Encourage Gordon to stop drinking alcohol. Alcohol causes fragmented sleep and suppresses REM sleep [27, 34] and also interferes with the normal function of GABA and glutamate, which are involved with wake–sleep states [34].

• Ensure Gordon’s nocturnal blood-sugar levels remain stable. Altered glucose metabolism is associated with sleep disorders [35, 54].

• Encourage Gordon to eat a low GI/GL diet to keep his blood glucose levels stable [14]. Hypoglycaemia or altered glucose metabolism is associated with depression [36, 37] as well as sleep disturbance [14, 35, 54].

• Encourage Gordon to increase consumption of tryptophan-rich foods such as turkey, salmon, bananas, legumes, fish, whole oats, nuts, seeds, soy and dairy. Tryptophan is beneficial for both depression and insomnia [12, 14, 19].

• Encourage Gordon to increase consumption of foods rich in omega-3 [15, 19, 48, 47].

• Encourage Gordon to consume a light snack containing tryptophan before bed [14, 27]. The snack will help maintain nocturnal blood glucose [27] and the tryptophan will support melatonin synthesis and reduce sleep latency [12, 14, 38, 39].

• Identify and manage food intolerances or sensitivities. Food intolerances can contribute to sleep disorders [13, 55].

Physical treatment suggestions

• In combination with dietary and lifestyle changes, Gordon may find acupuncture very helpful to improve his sleep [29, 30, 44].

• Massage therapy can improve sleep [31] and depression [32]. Massage combined with acupuncture is also beneficial [33].

• Hydrotherapy: daily ¼–1 hour neutral baths over several days [49], hot hydrotherapy shower 2–10 minutes twice a day [50, 53], followed by a cold foot bath and a cold stomach rub or a cold compress to heat the body prior to sleep [49, 51–53]. Hot full body steam bath excluding the head (Russian bath) followed by a short cold shower or cold mitten friction, cover the body and lie down straight away [49].

• Cool or tepid sponge bath prior to sleep [53]. Cold sitz bath brings on a sedative effect [53]. Hot sitz baths can be relaxing and promote sleep [49].

TABLE 10.40 HERBAL TEA

Alternative to black tea
HERB	FORMULA	RATIONALE
Oats seed Avena sativa	1 part	Antidepressant [18]; traditionally used as a nervous system nutritive and tonic [15] and for general debility [18]
Skullcap Scutellaria lateriflora	½ part	Nervine tonic [20, 43]; mild sedative [20, 43]; traditionally used for insomnia [20]
Vervain Verbena officinalis	1 part	Antidepressant [18]; sedative [18, 41]; nervine tonic [41]; combines well with oats and skullcap for depression [18, 41]

Infusion: 1 tsp per cup – 1 cup 3–4 times daily

TABLE 10.41 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
St John’s wort Hypericum perforatum	50 mL	Antidepressant [15, 17]; nervine [15, 17]
Zizyphus Zizyphus spinosa	80 mL	Sedative [20, 21]; hypnotic [20, 21]; indicated for use in insomnia [20, 21]
Valerian Valeriana officinalis	40 mL	Anxiolytic [15, 17]; mild sedative [15, 17, 44]; hypnotic [15, 17]; decreases sleep latency and increases sleep quality in poor sleepers [15, 40]; particularly beneficial for insomniacs with depression when combined with St John’s wort [17]
WithaniaWithania somnifera1:1 liquid extract	30 mL	Adaptogen [15, 17]; anxiolytic [15]; antidepressant [15]; mild sedative [17]; traditionally used for insomnia [15, 17]
Supply:	200 mL	Dose: 5 mL at lunchtime, 10 mL in the evening

TABLE 10.42 TABLET ALTERNATIVES TO HERBAL LIQUID (MAY IMPROVE COMPLIANCE)

HERB	DOSE PER TABLET	RATIONALE
Lavender Lavandula angustifolia	400 mg	Sedative [15]; anxiolytic [15, 20]; hypnotic [15, 20]
Withania Withania somnifera	1000 mg	See above
Valerian Valeriana officinalis	500 mg	See above
St John’s wort Hypericum perforatum	800 mg	See above

Dose: 1 tablet at lunchtime, two in the evening

Kava kava (Piper methysticum) 300 mg tablet before bed [15]

Mild sedative [15, 17, 20, 44]; hypnotic [15, 17, 20, 44]; skeletal muscle relaxant [15, 17, 20, 44]; kava kava may be taken in addition to the herbal tonic or tablet formula to get an initial improvement in sleep

TABLE 10.43 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
L-tryptophan 1000 mg at bedtime [12] NB: In Australia doses of tryptophan exceeding 100 mg are included in Schedule 4 of the Standard for the Uniform Scheduling of Drugs and Poisons (SUSDP) and require a medical, dental or veterinary prescription [45] or 5-hydroxytryptophan 100 mg daily [14, 44]The availability and sale of 5-HTP is restricted in many Australian states and territories	Serotonin precursor [12, 19]; tryptophan deficiency is associated with depression [42, 43]; 1000 mg dose reduces sleep latency [44] and reduces wakefulness without decreasing REM sleep [12]; the use of contaminated l-tryptophan has been linked to the development of eosinophilia-myalgia syndrome (EMS); caution should be exercised to ensure only high-quality tryptophan products are supplied [14]; immediate precursor to serotonin [12, 19]; beneficial in depression [12, 19] 100 mg 5-HTP daily increases slow wave sleep [44]
Magnesium (amino acid chelate, aspartate or orotate) supplement with 50 mg vitamin B6 [12, 14] Providing 250 mg elemental magnesium 45 minutes before bed [14]	Magnesium and vitamin B6 are required for conversion of tryptophan to serotonin [12, 14]; magnesium deficiency is associated with insomnia [19, 46]; magnesium deficiency is more common in the elderly [16]
Omega-3 fish oil capsules 4 × 1000 mg capsules 3 times daily providing a daily dose of approx. 2000 mg EPA [48]	Fish oil is effective in treating depression [12, 14, 19, 47, 48]; supplemental EPA provides significant benefits in treating depression [48, 56]