Practical Use of Integrative Medicine for Fatigue and Stress from Trauma and Grief

While there's a tremendous opportunity for integrative medicine to help patients struggling with fatigue and stress due to trauma and grief, it can also inflict harm, said Rashmi Muller, MD, at the 2023 Academy of Integrative Health and Medicine Annual Conference in San Diego, Calif.

“We cannot apply a wellness model to grief; we can't just send them off with mindfulness tools, said Muller, an integrative endocrinologist affiliated with Veterans Administration Greater Los Angeles Healthcare Medical Center and UCLA Santa Monica Medical Center. “We need to show true compassion to sit with them in their pain and suffering.”

A whole health approach to stress and fatigue from trauma and grief focuses on the patient’s mission, aspiration, and purpose. What it doesn’t include, explained Muller, is a reliance on hormone testing and mindfulness tools like meditation and yoga, which is often seen within integrative medicine.

When it comes to endocrine testing, Muller said there are three key caveats to consider, including:

1. Biotin assay immunoassay interference: Biotin can impair testing for thyroid, vitamin D, and sometimes troponin. “I always tell my patients taking biotin that it's okay to take biotin, but please stop three days before your lab testing.”
2. Chronic fatigue patients often have thyroid and adrenal symptom overlap: Before conducting in-depth hormonal testing, Muller suggests that clinicians use their best judgment to assess the likelihood that a patient truly has endocrine disease. “I want to highlight that there are high specificity thyroid symptoms including loss of the lateral half-third of the eyebrow, edema, scaly skin, and if they’re hyperthyroid, they might have a fine tremor.”
3. Adrenal and stress hormone: An a.m. cortisol level greater than 28 rules out adrenal insufficiency. An a.m. serum cortisol level greater than 50 is concerning; in that case, a late-night salivary cortisol is very useful. “Endocrine diagnosis is based on screening tests and then provocative testing to ensure that abnormality is real.”

Muller went on to explain that hormone production is tightly regulated. “A single hormone measurement at a single point in time does not tell us anything about the patient's clinical picture,” she said. Without the complete clinical picture, integrative practitioners will often put their patients on unnecessary supplements.

“Casting a wide net to address the hormonal cause of fatigue from stress can actually be harmful, and it's really inaccessible,” Muller said. “A lot of these tests are just too expensive for the patients who are struggling with chronic trauma and stress, and micronutrient and adapting genic supplements aren't always safe.”

While she warned against indiscriminate testing, Muller said there is a place for targeted, clinically informed evaluations. For instance, for thyroid axis testing, she routinely measures thyroid stimulating hormone (TSH), free thyroxine (T4), and free and total triiodothyronine (T3). “You can essentially put someone into a category of likely where they fall based on these three tests.”

Another pitfall of integrative care for grief is its focus on mindfulness to promote healing. Referring to a study about an online yoga program for women who experienced stillbirth, she pointed out the potential harm such approaches could inflict, calling them a form of toxic positivity. Imposing a healing modality like yoga on individuals grappling with profound grief might inadvertently marginalize their pain. “We must be careful when implementing integrative interventions in vulnerable populations. We need to think about what we are funding with our research and why we are doing it,” Muller said.

Instead of rushing grieving patients into mindfulness exercises or meditation routines, what’s really important is giving them space to heal. “We need to meet patients where they are,” Muller said, noting that sometimes what grieving individuals need most is a simple acknowledgment that “it’s okay to not be okay.”

To Muller, practical, integrative interventions for grief and trauma prioritize safe spaces and the role of spirit, whether that be within the patient or the spirit within the loved one with whom they’re trying to connect. She said therapies like expressive arts can be especially helpful when trying to explore the depths of emotion.

“The trauma-informed care framework recognizes the role that trauma can play in an individual's life, but it does not require that we ask patients to divulge their trauma history. We don't need patients to relive all that for us to believe them,” Muller said. “All we need to do is provide a safe space to share. And we need to be especially careful in medical settings and hospital settings where many patients have experienced trauma.”

Editor's note: This article is part of our live coverage of the 2023 Academy of Integrative Health and Medicine Conference. Click here for a list of full coverage.