Case Study Excerpt: An Integrative Approach to Mental Health and Chronic Stress

Patient Information

Ben is a 43-year-old attorney living in the greater Washington D.C. area. He is a partner at a top-tier firm with long hours spent meeting clients and traveling for work. He and his wife are both busy with their careers and spend a limited amount of time together during the week, though they do go to dinners or gatherings on the weekend, often with work colleagues or clients.

Problems:

• Chronic stress
• Insomnia

Allergies:

• Seasonal

Social History:         

• Smoking: Non-smoker
• Alcohol: 1-2 drinks on most days, heavier drinking (3+ drinks) on Friday and Saturday

Vital Signs:

• Height: 5’10”
• Weight: 175 lbs
• BMI: 25.1
• Total cholesterol: 175
• HDL cholesterol: 60 mg/dL
• Blood pressure systolic: 140 mm Hg
• Blood pressure diastolic: 90 mm Hg
• Non-fasting glucose: 120 mg/dL

Medications:

• Occasional ibuprofen

Health Concerns:

• Tightness in chest
• Trouble focusing
• “Racing” heart and fast heart rate

Practitioner Perspective: Peter Bongiorno, ND, LAc

Peter's priority with Ben is understanding his story and schedule to identify what is realistic and meaningful for him and his lifestyle.

First Visit

The first visit for Peter and Ben would be 90 minutes in length, and would include mostly discussion, as well as recommendations for testing and starting to look at different aspects of care and recommendations for diet and lifestyle.

Peter would want to sit down with Ben and get to know him and his full story. He would ask lots of questions to find out what he was there for. Peter would start by asking the magic wand question: What would be better or more balanced if he waved a magic wand? He said this is a nice way to break the ice and focus on what's bothering the patient.

They would also go over Ben’s health history. As they were talking, Peter would start writing out ideas and notes for him that they would go over towards the end of the visit and print out so it's clear what they're working on.

Care Plan

Initially, Peter may make different recommendations for testing, such as adrenal function, blood profile including blood sugar and inflammatory markers, nutrients like vitamin D, vitamin B12, zinc, copper, and magnesium, and potentially thyroid function. Peter would also ask Ben to keep a blood pressure diary to check in and learn more about what’s going on.

Up front, the most glaring issue Peter would want to address is Ben's sleep. Peter would encourage Ben to get more sleep than his current four to five hours and likely discuss his schedule. Understanding his schedule and what his parameters are would help Peter make recommendations that are realistic for Ben. Getting more sleep could be a big piece of why his blood pressure is going up, and he's consistently tired.

From there, Peter would want Ben to start to do some simple exercises once he's getting some sleep. He would also want to check in on hydration and make sure he's drinking enough water. Peter said oftentimes, patients wake up in the middle of the night with their hearts pounding because they're dehydrated.

Additionally, Peter would want to explore bringing in some mindful eating techniques and having Ben take a minute to breathe when he sits down for a meal. This can easily be incorporated if he’s eating out. Additionally, since Ben eats out so much, Peter said it’s unrealistic to have him start eating all his meals at home, but they would work together to pick good quality meals that would be better for him.

Peter would also encourage Ben to minimize coffee as well, as it could be part of the reason why he’s experiencing burnout and struggling with sleeping. If he’s reliant on coffee, Peter would work with Ben to slowly reduce consumption by mixing in decaffeinated coffee and incorporating B vitamins, which can help with withdrawal from coffee. 

For additional supplementation, Peter would likely recommend nutrients to support the heart, depending on what his lab tests reveal. Since Ben is 43 years old, his adrenals are likely dysregulated, so Peter would also look at supplements that are both calming but support focus and energy when needed. This may include:

• Magnesium glycinate for anxiety or racing thoughts
• Nutritional lithium to calm the stress system
• Ashwagandha
• Green tea

Lastly, Peter would urge Ben to avoid alcohol, especially given his heart symptoms. He’s find out exactly why Ben takes occasional ibuprofen and how often he takes it, and see if they can work in a natural alternative. Ibuprofen can also raise blood pressure, so he’d educate Ben on that.

Beyond diet and lifestyle recommendations, Ben’s treatment with Peter would also incorporate acupuncture, which would calm his body, balance energy, and allow him to relax.

Peter would want to see Ben once a week for 60 minutes. Visits would include 10 to 15 minutes to check in and make adjustments to his care plan, followed by acupuncture treatment. Peter would anticipate weekly visits for eight weeks and then space out visits every two to three or three to four weeks after that.

Case Considerations

Peter would want to find out what Ben’s schedule is, including what’s negotiable versus non-negotiable. This would help Peter optimize the care plan to work for Ben. Then, Peter would find out what Ben is willing to do. For example, if Ben wants to get more sleep and his day off is Saturday, they would explore going to bed early on Friday and sleeping in Saturday morning. This would be a starting point for Ben to get more sleep, and they could progress from there.

Additionally, Peter would recommend different ideas for Ben and get a sense of what he's interested in doing, which will likely garner the best results. For example, Peter would love for Ben to meditate, but if it's a foreign concept for him, they might start slow with one or two minutes or simply taking a walk outside.

When Ben feels chest tightness, it’s his body speaking to him and telling him that he can’t keep going on in this way, Peter said. He would want Ben to start to be aware of his own body, as well as the relationship between his body and his thoughts, and present the conversation in a way that is interesting and speaks to him.

Peter would also explain that by working together and making changes, his work efficiency will improve. He will experience myriad benefits— his focusing and racing heart will get better, the tightness in his chest will improve, it won't take as long for him to complete projects, and he'll feel less run down and burned out.

Long-Term

Peter would want to see if it's possible for Ben to create a schedule that is more supportive of a healthy lifestyle. What he's doing is unsustainable in the long-term, Peter said, and now his body is starting to speak back. Therefore, in the long term, he would want Ben to change his schedule.

If Ben likes his work and wants to continue doing it, that’s fine, but Peter would encourage Ben to use this time to assess and find more so they can start to make changes that align with his goals. Peter would also want to understand what makes Ben happy and reprioritize what he wants to do. Peter’s long-term goals for Ben go along with what his long-term goals are. 

Editor's note: This article is an excerpt from the e-book, Mental Health and Chronic Stress: An Integrative Medicine Case Study. To read more, click here.