Woman - Psychosomatic Gynaecology and Obstetrics (2014) 1, 1—11
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Exploring the aspect of psychosomatics inhypothyroidism: The WOMED model ofbody—mind interactions based onmusculoskeletal changes, psychologicalstressors, and low levels of magnesium
Roy Moncayo ∗, Helga Moncayo
WOMED, Karl Kapferer Strasse 5, 6020 Innsbruck, Austria
Received 1 November 2013; accepted 14 February 2014Available online 12 March 2014
Summary Patients with hypothyroidism can present a series of so-called residual symptomswhich are said to be without physical pathology. These symptoms, however, affect negativelythe well-being state of these patients. Currently there are no explanations for this situation.
Based on previous investigations done with thyroid disease patients we have carried outa clinical examination which is centered on musculoskeletal features together with a simpleevaluation of psychological stressors (scaled 1—3). Laboratory diagnosis was focused on serummagnesium. This report includes the data from 166 women including 58 euthyroid controls (sixmales) and 108 patients with hypothyroidism (eight males).
The most common complaints seen in our patients included fatigue, being easily tired, con-centration deficit, ankle instability, and gait insecurity, giving way of the ankle, muscle crampsin the shanks, visual disturbances, irritability, and vertigo sensation. Besides this symptomato-
logy a great majority of the patients (89.5%) presented musculoskeletal alterations. The mainfinding was that of lateral tension which entails an eccentric muscle action of the affected lowerextremity. Lateral tension was always accompanied by (forward) rotation of the hemi-pelvis ofthe affected side. Idiopathic moving toes were found to be independent of lateral tension.Stress scores in patients were higher in patients than in the control group. Serum magnesium levels were significantly lower in patients (0.87 ± 0.1 mmol/l vs. 0.92 ± 0.07 mmol/l, p = 0.041)
ince almost a decade we have been involved in the diag-osis and treatment of benign thyroid disease. Within thisrame we have been repeatedly confronted with a — now
standard situation where patients that are being treatedither for hypo- or hyperthyroidism and who have unre-arkable laboratory results still present residual complaints
hat do not respond to thyroid treatment. Such patients areonsidered by experts in thyroid disease to be actually suf-ering from psychosomatic illness (Weetman, 2006). Theseatients place a dilemma since practitioners consider thathese symptoms have no physical pathology (Burton, 2003).ne possible approach could be to handle the topic as beingedical unexplained symptoms (MUS) and consider them to
‘refer to bodily symptoms that do not have a physical healthxplanation’’ (Gask et al., 2011). By this, patients are leftlone.
Ott et al. (2011) have enumerated such residual symp-oms seen in patients with Hashimoto’s thyroiditis includinghronic fatigue, dry hair, chronic irritability, chronic ner-ousness, a history of breast cancer and early miscarriage,nd lower quality-of-life levels. In a similar fashion Samuelst al. (2007) described psychological symptoms and/orognitive dysfunction in patients being treated with thy-oid hormone. Jonklaas and Burman (2013) described thatreated patients with hypothyroidism present less psycho-ogical well-being and more fatigue. In a more generalay, one can find several publications dealing with stressr stressful events, panic disorders in thyroid diseaseMaranon, 1921; Lidz and Whitehorn, 1950; Mandelbrote andittkower, 1955; Gray and Hoffenberg, 1985; Winsa et al.,
991; Harris et al., 1992; Harsch et al., 1992; Sonino et al.,993; Kung, 1995; Radosavljevic et al., 1996; Matsubayashit al., 1996).
These reports — and others in the literature — pointoward a dual problem in clinical practice, i.e. how to deal
nd explain the remaining symptoms in these patients andow to treat them? This apparently unexplainable situationas motivated us to search for an explanation as well as for
treatment for such patients.
Bsu
. Patients and methods
.1. The environment
e carry out our clinical work at a private institu-ion (WOMED, Innsbruck, Austria, http://womed.at). Ourrimary work is in the field of endocrinology covering repro-uctive medicine including in vitro fertilization (HM) andhyroid diseases (RM). Through time we have developed anntegrative approach in our practice that is based on theollowing techniques: Applied Kinesiology (Walther, 2000),CM, Western herbs, sports medicine, and manual medicine.esides this, body—mind techniques such as Reiki and Shuarhamanism, are available. This combination is what we callhe WOMED model.
.2. Patients
his report includes the data from 166 women including8 euthyroid controls (six males) and 108 patients withypothyroidism (eight males). Every patient is examined fol-owing our previously described strategy that is aimed atdentifying alterations of the musculoskeletal system. Theain alterations that can be found include lateral tension,
diopathic moving toes (IMT), and leg length discrepan-ies associated with rotation of the hemi-pelvis (Moncayond Moncayo, 2007). A follow-up examination was done—6 months after the patients received a supplemen-ation regime consisting of a magistral prescription of pureagnesium citrate t.i.d. containing 1.4 mmol elementalagnesium per capsule.All procedures were done in accordance with the Decla-
ation of Helsinki (World Medical Association, 2000).
ased on the description made by Parry on the association oftress and fright with thyroid disease (Parry, 1825) we eval-ated the presence of psychological stressors. The specific
Exploring the aspect of psychosomatics in hypothyroidism
questions related to stressors included: (1) History of a trau-matic situation, e.g. psychological or physical trauma as achild or care deprivation as a child. (2) Current stressful sit-uations at home or at work or in connection with educationchallenges (e.g. term examinations at a university). (3) Gen-eral feeling of anxiety and/or feeling of fear, panic attacks.These items are a simplified reduction of the items origi-nally described by Rahe et al. (1964) who used the Scheduleof Recent Experience. A quantification of the magnitude ofsuch events as presented by Holmes and Rahe (1967) wasnot pursued by us. In our study the maximal score was 3. Forsubjects having a score of 2 or 3, a relaxation or stress reduc-tion treatment was done as described by us before (Moncayoet al., 2006). The subjective symptoms of the patients wererecorded individually.
2.4. Laboratory parameters
Laboratory parameters investigated included thyroid func-tions tests as well as serum magnesium levels. Magnesiumsupplementation was indicated when the laboratory resultwas <0.9 mmol/l. This lower level of magnesium is derivedfrom our own data based on healthy subjects with normalthyroid function.
2.5. Statistics
IBM SPSS Statistics 21 was used to analyze the data.
The most common complaints seen in our patients includedfatigue, being easily tired, concentration deficit, ankleinstability, and gait insecurity, giving way of the ankle, mus-cle cramps in the shanks, visual disturbances, irritability,and vertigo sensation.
The clinical examination revealed lateral tension in 10.5%of the controls and 89.5% of the patients. Among thehypothyroid patients lateral tension was found to be one-sided in 85.2% of the cases and two-sided in 14.8%. Idiopathicmoving toes were found only in 39 cases corresponding to7.7% of the controls and 92.3% of the patients. Lateral ten-sion findings were found to be associated with rotation of thehemi-pelvis of the affected side. The most common findingwas that of an anteriorly rotated hemi-pelvis. Hypothyroidpatients also presented a blockade of pelvic motion duringrespiration. The most common finding was that of inspirationblockade (Walther, 2000; Cuthbert and Rosner, 2011).
A total of 142 subjects provided data for the stress scoreevaluation. The number of controls and patients presentingdifferent stress scores were: score 1: 33 vs. 9, score 2: 13 vs.54, and score 3: 4 vs. 29, respectively. Our initial relaxationtreatment procedure was expanded to include acupunc-
ture with a neutral needling technique on acupoints locatedalong the Triple Burner meridian (SJ3—SJ9) as well as theacupoint Stomach 15. The identification of these points ineach patient was done using Applied Kinesiology techniques
b(tp
igure 1 Box-plot of the magnesium levels in relation to thetress score.
hat related them to the known psychological stressors.xperienced body—mind practitioners can directly identifyhese points of accumulated trauma energetics (Oschman,006). By this, treatment of psychological stressors is spe-ific for each patient.
.2. Magnesium levels
he mean levels of magnesium were significantly highern the control group as compared to hypothyroid patientscontrols 0.92 ± 0.07 mmol/l, patients 0.087 ± 0.1 mmol/l,
= 0.041). Since the magnesium levels were below thehreshold of 0.9 mmol/l, all patients received supplemen-ation with magnesium citrate.
Significantly lower levels of magnesium were seenith increasing stress scores only in the hypothyroidroup (controls: stress score 1: 0.95 ± 0.06 mmol/l, stresscore 2: 0.95 ± 0.04 mmol/l; patients: stress score 1:.89 ± 0.11 mmol/l, stress score 2: 0.87 ± 0.10 mmol/l,tress score 3: 0.85 ± 0.11 mmol/l; p = 0.005; Fig. 1).lthough the statistical analysis did not reveal significantifferences in magnesium levels In relation to either lat-ral tension or IMT, we observed a trend toward loweragnesium levels in the hypothyroid group with increasingusculoskeletal involvement (Fig. 2).
.3. Follow-up examination
fter 3 months of supplementation with magnesium citratehe incidence of IMT dropped while that of lateral tensionersisted. Persisting lateral tension was then treated
y acupuncture using the acupoints described elsewhereMoncayo and Moncayo, 2007; Moncayo et al., 2007a, 2007b)ogether with manual medicine procedures to correctelvic hemi-rotation (Walther, 2000). Respiratory muscle
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igure 2 Box-plot of the magnesium levels in relation to lat-ral tension.
nhibitions required at the most two sessions of correction.n few patients emotional feelings (sadness, need tory) appeared during the correction of the musculoskeletallterations. A successful treatment was generally associatedith sensation of warmth in the body followed by tiredness.
Clinical symptoms resolved in 90% of patients after 6onths of supplementation. The most common improve-ents were related to a better feeling of well-being, less
atigue, having more energy, improved capacity to concen-rate, and less anxiety. One condition usually not mentionedt the initial examination was that of constipation. Follow-ng magnesium supplementation patients did not have thisomplaint.
The small group of patients that did not attainmprovement (10%) was confronted with complex traumaticituations at early age. For this reason these patients hadlready had psychotherapy. Patients who stopped takingagnesium citrate, e.g. did not take the supplement dur-
ng vacations or on a trip, experienced again some of thenitial complaints. Side effects of magnesium intake, suchs diarrhea, were not seen in any patient.
. Discussion
n this series of patients with hypothyroidism we have beenble to identify two forms of stressors, i.e. physical and psy-hological. Serum levels of magnesium were significantlyow in hypothyroid patients and showed a trend towardower levels in relation to higher stress scores. The com-ined therapeutical approach based on supplementation
ith magnesium citrate together with a relaxation treat-ent and acupuncture, as well as a manual medicine to
orrect the musculoskeletal changes, has been found toe successful in 90% of the cases. This success has been
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R. Moncayo, H. Moncayo
ccompanied by resolution of the so-called psychosomatic oredical unexplained symptoms. It follows that patients with
ypothyroidism present a situation that has more complexityhan just decreased production of thyroid hormones. Unfor-unately, this complex situation has not been recognized byther practitioners (Weetman, 2006).
In order to maintain scientific correctness in times ofvidence-based medicine we must declare that no compa-able method to ours, i.e. any standard, can be found in theiterature.
We hypothesize that the presence of both types oftressors augments the daily need for magnesium supply.ur explanation for magnesium need in face of the mus-uloskeletal changes is centered on the eccentric musclection that is associated with lateral tension (Moncayo andoncayo, 2007). The stress-like symptoms of magnesiumeficiency have been described by Seelig (1994) many yearsgo. Grases et al. (2006) have shown that anxiety and stressmong students is related to increased magnesium loss, aituation which correlates with stress scales. An interestingbservation made by these investigators was: ‘‘The notice-ble increase in muscular tension linked to anxiety consumesn important amount of energy that is partially due to theTP—ADP transformation’’ (Grases et al., 2006). We willeturn to this feature in section ‘Energetic aspects of mag-esium and female reproductive functions’.
One feature that has hampered the recognition of mag-esium deficiency has been the vague definition of normalagnesium levels while at the same time the problem ofagnesium deficiency is increasing in modern life (Elin,
010; Crosby et al., 2013). As we show in this study, controlubjects without thyroid disease have a mean magnesiumevel of 0.92 mmol/l. This value is our current referenceevel.
.1. Questionnaires on residual symptoms inypothyroidism — what can be done?
e have looked for evidences regarding residual symptomsn patients with hypothyroidism and how to treat them.nfortunately we found no therapeutical recommendations
n these publications. We will shortly describe the findingsf these studies.
Romijn et al. (2003) have described symptoms such asusculoskeletal complaints, vague feelings of being unwell,
s well as depression in relation to the adequacy of thy-oid hormone replacement therapy for hypothyroidism Annteresting remark made by the authors stated: ‘‘In clini-al practice, these complaints are difficult to quantify bylinimetric methods or by biochemical testing’’. Jaeschkepproached this situation evaluating disease-specific andeneral HRQL items (Jaeschke, 1996). They describe thatymptoms and substitution treatment did not fit together.ianchi et al. (2004) have described alterations on health-elated quality of life in patients with thyroid disordersased on the use health questionnaires. Their study showedhat hypothyroid patients scored poorer. Samuels et al.
2007) used a whole battery of questionnaires includinghort Form 36 (SF-36); Symptom Checklist 90 — Revised (SCL-0-R); Profile of Mood States (POMS); and tests of declarativeemory (Paragraph Recall, Complex Figure), working
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tprocesses through muscle function. Generation of energyand regeneration of skeletal muscle are essential. Althoughsome scientific descriptions of muscle function might appearto include a reductionist point of view, i.e. single groups of
Exploring the aspect of psychosomatics in hypothyroidism
memory (N-Back, Subject Ordered Pointing, Digit Span Back-wards), and motor learning (Pursuit Rotor) (Samuels et al.,2007). The findings of the study included significant decre-ments in health status together with increased psychologicalstress in hypothyroid patients receiving treatment (Samuelset al., 2007). Watt et al. (2006) conducted an evaluation ofthyroid-related quality of life items. In this review they iden-tified both musculoskeletal symptoms as well as fatigue in ahigh proportion of patients with hypothyroidism (Table 2 inWatt et al., 2006). In spite of having identified possibly rele-vant issues, there is no mention as how to approach and treatthese patients. van de Ven et al. (2012) investigated the itemof fatigue perception in euthyroid subjects using the RAND-36 and the shortened fatigue questionnaire (SFQ). Personsthat had thyroid disease, either hypo- or hyperthyroidism,were found to experience more fatigue as compared to thegeneral population. In the group of subjects with normal thy-roid function 34% presented also fatigue. Even the inclusionof genetic markers in an investigation in relation to fatiguein hypothyroid patients has not provided any further insightinto this symptomatology (Louwerens et al., 2012).
In our opinion the use of questionnaires or polls are simplystatistical, demographic methods. The lack of basic informa-tion that can be taken from a thorough clinical examinationdoes not fully qualify them as being a validated test for clini-cal purposes. By using a simplified stress evaluation score wehave been able to decide when to add additional treatmentmeasures (Moncayo et al., 2006).
4.2. Theories of resilience, salutogenesis, andsomatization
Resilience has been recently used as a main research com-ponent in an investigation on psychosocial contributors toillness and disease (Ryff et al., 2012). Ryff defines resilienceas: ‘‘the maintenance, recovery, or improvement in men-tal or physical health following challenge’’. For her it is aworking formulation of the term. Going back to the roots ofthe term Ryff et al. refer to the definition of resilience asgiven by Rutter in 1990 as being the positive component ofan individual’s response to stress and adversity. In a similarway Antonovsky’s Salutogenesis involves the continuous setof challenges and adaptive responses (Antonovsky, 1985).While this attitude can be called ‘‘positive’’ our patientshave real stress burdens that cannot simply be overcomeby being optimistic. This type of burden was apparentlypresent in 10% of the patients. One interesting statementbrought by Lipowsi states: ‘‘Somatization, a tendency toexperience and communicate somatic distress in responseto psychosocial stress’’ (Lipowski, 1988). Psychosocial stressis not only limited to psychosocial changes. Newer lines ofinvestigation are relating early traumatic situations whichcan influence multisystem resiliency and even affect telom-ere length (Puterman and Epel, 2012). One of such earlytraumatic situation can be childhood maltreatment, whichalso affects telomeres (Tyrka et al., 2010).
In 2008 Garner and Boles presented evidence linking
diminished mitochondrial function of Complex I of oxidativephosphorylation to symptoms of somatization. The conclud-ing remarks include the following postulate: ‘‘We proposethat energy depletion constitutes at least part of the
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nherited biological predisposition toward the developmentf depression with somatization predicted by Freud’’Gardner and Boles, 2008). It has to be mentioned that thetems of their score system bear some similarities to theymptoms which we have found through the exploratorynvestigation.
We postulate the foundation of resilience as well as thatf Salutogenesis is related to the physical, material, bio-hemical condition of magnesium levels. Our results showhat in order to support the innate resources of healing theubjects need an optimal magnesium supplementation.
n order to follow the concepts contained in our WOMEDodel it is necessary to expand the scope of the discussion
n order to include concepts of thermodynamics as well asf mind—body techniques. These topics are seldom broughtn medical education, thus practitioners are not aware ofhese aspects.
The field of thermodynamics has provided some basicrinciples as to the way how living organisms are orga-ized and how they function. In the writings of Schrödinger1948) one can find the notion that the existence of liv-ng systems is within a world of energy and material fluxes.rigogine et al. (1972a, 1972b) presented his theory of livingrganisms as being dissipative structures where evolutions related to increased flows of energy and at the sameime of successive perturbations or bifurcations. In a modernnalysis of thermodynamics one finds the notion that: ‘‘. . .
oth cell and ecosystems have common energetic traits. Inoth systems stress and/or aging will result in lower energyow and lower specific entropy production’’ (Toussaint andchneider, 1998). Going beyond the second law of thermo-ynamics Corning postulates: ‘‘. . . we believe that the rolef energy in evolution can best be defined and understoodn economic terms. By this we mean that living systemso not simply absorb and utilize available energy withoutost. They must ‘‘capture’’ the energy required to buildiomass and do work; they must invest energy in devel-pment, maintenance, reproduction and further evolution’’Corning, 2002). Thus energy production, energy flow, andotential perturbations have to be kept in mind. Wallaceommenting on the 2nd law of thermodynamics states: ‘‘In
thermodynamically isolated system, complex structuresecay toward randomness. However, in non-equilibrium sys-ems, the flow of energy through the system generates andustains structural complexity, and non-homogeneous struc-ures embody information’’ (Wallace, 2010).
Besides these theoretical elements we have to considerhe fact that we are daily involved in generating energy
1 An oral presentation entitled ‘‘Modelo de Bio-Energética y elistema Muscular’’ was held in Quito, Ecuador, on October 24th,013.
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uscles, single muscle fibers or even cell culture, one haso rather consider the total musculoskeletal system which isonstantly working. Jaynes, in an unpublished manuscript,as discussed the function of muscle action and their effi-iency according to the 2nd law of thermodynamics (Jaynes,983). The basic elements of muscle contraction and actionave been described by Szent-György (Banga and Szent-yörgyi, 1942; Szent-Györgyi, 1949, 2004) as well as byuxley (1969). These investigations bring us to the mech-nisms of muscle contraction including the definition of theunction of myosin. Myosin alone, however, is not the sourcef energy: ATP has to be considered (McClare, 1975) and thisituation brings us to the point where substrates, i.e. magne-ium as magnesium-ATP, are required (Szent-Györgyi, 1949,004). In the process of oxidative phosphorylation the gen-ration of ATP departs from the complex magnesium ADP. Itollows that lack of magnesium could lead to a dysfunctionf Complex V of the respiratory chain.
While Western medicine tends to apply reductionistsiews in order to describe disease assigned to an organ,ntegrative concepts of body function are found rarely inestern medicine. On the other hand such integrative con-
epts are living elements in TCM and osteopathy. In TCM,he so-called extraordinary meridians provide pathways thatelate the feet to the head, i.e. the Yin quiao mai, Yangiao mai, Yin wei mai, and Yang wei mai meridians. Othereridians integrate the mid-line of the body, i.e. the Chongai, Dai mai, Ren mai, Du mai (Ellis et al., 1989; Matsumoto
nd Birch, 1986; Kirschbaum, 2000). One special concept inCM is that of an organization within meridians based on theeachings of antique acupuncture points (Hicks et al., 2004).e have demonstrated these integrative principles in rela-
ion to manual muscle tests using surface electromyographyMoncayo and Moncayo, 2009). Osteopathy has relied onuch integrative concepts since its beginnings (Still, 1899).ndrew T. Still when describing the osteopath he stated:‘He sees cause in a slight anatomical deviation for theeginning of disease. Osteopathy means a knowledge ofhe anatomy of the head, face, neck, thorax, abdomen,elvis, and limbs, and a knowledge why health prevails in allases of perfect normality of all parts of the body’’ (Still,902). Equivalent or similar concepts of regulation can beound in the description by Luigi Stecco on fascial manip-lation for musculoskeletal pain published in 1988 (Stecco,004). Modern textbooks of osteopathy describe these inte-rative concepts in the form of chains (lateral chain, centralhain, etc.) (Paoletti, 2001). We propose that coordinateduscle action can be considered to be an equivalent of
in-Yang balance between agonist and antagonist muscleroups. This description can be taken as an explanation ofi as the innate energy being generated by muscles withinhe biochemical frame of magnesium-ATP. The De-Qi feel-ng is the propagation of muscle action following similaro the undulation waves described by Chen (Chen et al.,011a, 2011b, 2012). Conservation of this propagation effectequires integrity of the system. Integrity means health.
What happens in a traumatic situation? Altogether,rauma can alter the basic function of muscle. In the
ords of McMakin and Oschman (2012): ‘‘Residual local
ensions and gluing in the fascial network can give riseo compensating tensions extending throughout the mus-uloskeletal system. Such compensations can disturb more
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R. Moncayo, H. Moncayo
istant structures, leading to compromised movement pat-erns that leave the body vulnerable to further injury’’. Thists well into our description of the model of lateral ten-ion (Moncayo and Moncayo, 2007). A more general view ofody energetics is that of the Biofield (Rein, 2004). Somemportant elements described here include: ‘‘the conceptf bio-information which, mediated by consciousness, func-ions globally at the quantum level to supply coherence,hase, spin, and pattern information to regulate and healll physiologic processes. This model is used to explain aide variety of anomalies reported in the scientific litera-
ure, which cannot be explained by traditional biophysicsnd bio-electromagnetics’’.
While basic medical sciences limit themselves to specificrocesses of single organ systems, Tataryn has presented
connecting model where: ‘‘. . . the mind—body paradigmxtends the body paradigm to include factors such astress, psychologic coping styles, and social supports as pri-ary determinants of health and disease. The body-energyaradigm assumes health and disease are functions of theow and balances of life energies (Tataryn, 2002). Theselements allow us to understand and to follow pleas towardn integration into ‘‘complex disease’’ . . ..’’ (Knox, 2010). In
review on holistic medicine, Ventegodt has described thentegrative characteristics of the ancient medical systemsrom India, China, and Greece. The authors stress the pointhat treatment of traumatic events should not be limitedo the present time. Old traumas have to be consideredoo. If they are not approached they — and their organic-sychical stigma — will remain (Ventegodt et al., 2007).unctional neuroimaging gives interesting information aboutNS substrates involved in mental processes that relate pastxperiences to present and future ones (Szpunar et al.,007). These cortical areas show relation to both memoryrocesses as well as to those related to motor imagery ofodily movements, i.e. the musculoskeletal system. Szpunart al. (2007) speak from ‘‘reactivation of previously expe-ienced visual—spatial contexts’’. In our current approachor treating situations of negative recalls we work in a wayimilar to that used by Szpunar on contextual processingFigure 2 in Szpunar et al., 2009) as well as that describedor counterfactual thinking (Van Hoeck et al., 2013). Coun-erfactual thinking is activated in conflicting situations whenubjects consider alternatives to past events (Epstude andoese, 2008, 2011).
We will now discuss some selected aspects of energeticork. Growing up in Ecuador (RM) Shamanism is an everresent integral element of life. In Shuar language uwishineans ‘‘powerful wisdom’’. This wisdom has been pre-
erved in spite of attempts to undermine these indigenousractices through the Spanish conquerors. These interac-ions and developments in areas that were submitted to thepanish conquista have been described by Chaumeil (1992).he shaman can visualize the past situations that have ledo energy accumulation which are called tsentsaks. Theseapabilities fit well into the concept of mental time travelSuddendorf and Corballis, 1997; Tulving, 2001; Blanket al., 2005; Zentall, 2006; Arzy et al., 2008; Berntsen and
acobsen, 2008; Botzung et al., 2008; Quoidbach et al.,008; Arzy et al., 2009; Piolino et al., 2009; Suddendorft al., 2009) and out-of-the-body experience (De Riddert al., 2007). This characteristic is shared in the noetic
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Exploring the aspect of psychosomatics in hypothyroidism
approach, i.e. that of inner knowing and the relation toan outer sphere. Suddendorf has provided descriptions ofnoesis and mental time travel (Suddendorf and Corballis,1997; Suddendorf et al., 2009). In the 1997 article mentalreconstruction of personal events from the past is describedas: ‘‘. . . episodic memory, enabling conscious recollectionof past episodes, can be distinguished from semantic mem-ory, which stores enduring facts about the world. Episodicmemory shares a core neural network with the simula-tion of future episodes, enabling mental time travel intoboth the past and the future’’. Tulving and co-workershave described functional electro-physiological correlatesof these processes (Cabeza et al., 1997; Düzel et al., 1997;Wheeler et al., 1997; Nyberg et al., 2010). One importantaspect that is reflected in energetic work is the memory ofprevious emotions (Van Weelden, 1997). Psychological prim-ing with negative situations can be associated later in lifewith anger, depression, and anxiety (Van Weelden, 1997).The field of cognitive neuroscience describes the processesof embodied and disembodied paradigms that are reflectedin the mental-scene (Stocker, 2012). Embodiment has alsobeen used in anthropological research as a way to study cul-ture and the self (Csordas, 1990). A modern term is now inuse, namely ‘‘neuroanthropology’’ (Campbell and Garcia,2009).
4.4. Energetic aspects of magnesium and femalereproductive functions
The musculoskeletal aspects which we deal with here havepotential metabolic consequences since they are closelyrelated to body energetics. The fundamental aspect in ouropinion is that of ATP synthesis which requires magnesiumin Complex V of oxidative phosphorylation (Ko et al., 1999;Beard, 2005). Lack of magnesium could turn oxidative phos-phorylation inefficient.
In the field of Anthropology the issue of energetics hasbeen followed closely. Jasienska and Ellison (1998) showedthat physical work causes suppression of ovarian function inwomen due to high levels of energy expenditure. The sub-jects they studied had low levels of salivary progesterone.They found that the only factor having a significant directeffect on ovarian function was energy expenditure. Moderninvestigations have demonstrated that work-related exhaus-tion is related to shorter telomere length (Ahola et al.,2012). Besides these data on menstrual cycle characteris-tics, energetics of pregnancy and lactation is an equallyimportant issue for energy balance and fertility (Dufourand Sauther, 2002). Suppression of activity of the repro-ductive axis together with decreased fertility is correlatedwith stress intensity. This stress can be in the form of lowfood energy intake as well as from increased energy expendi-ture in physical activity (Bullen et al., 1985; Williams et al.,2001). In later age cycle disturbances could add to psy-chosocial stress when fertility problems arise (Oddens et al.,1999). Such changes can also be seen in the setting of in vitrofertilization (Klonoff-Cohen et al., 2001).
In an analysis of the energetic cost of walking, Kramerand Sylvester (Kramer and Sylvester, 2011) start off by men-tioning the fact that energy availability is limited and thatreproductive functions can suffer negative changes since:
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‘energy used to move is lost to reproduction, an activ-ty that is both energetically intensive for mothers’’. Thenergetic demand is not only related to walking but also toosture. Even though bipedalism can be seen as being eco-omical concerning locomotor energy (Pontzer et al., 2009),he effect of load-carrying, such as carrying a child, adds
further dimension into the energetic needs of women.atson et al. (2008) showed that one sided load carry-
ng, e.g. a mannequin on one hip (similar to carrying ahild), was coupled with higher energy requirement. Otheruthors have also analyzed the increased energy require-ent involved in infant carrying both in humans as well
s in animals (Wall-Scheffler et al., 2007; Altmann andamuels, 1992). Combining this effect of energy need forhild-carrying to the axial displacement associated with lat-ral tension rounds up a musculoskeletal component thatill influence negatively the energy balance and lead partly
o ‘‘psychosomatic’’ changes post-partum (Bokhari et al.,998; Groer and Vaughan, 2013).
.5. Can our results find support fromxperimental data?
ome studies done under experimental conditions can beaken as indirect evidence for our findings. One key findingn our opinion is that made by Sartori et al. (2012) show-ng a relation between magnesium deficiency and anxietys well as the initiation of the hormonal stress reactioneginning at the level of CRH. In a clinical and experimen-al review, Classen et al. (1995) have described the usef magnesium supplementation to overcome stress. Furtherata has shown a relation between magnesium status andmotionality (Laarakker et al., 2011) as well as enhance-ent of learning by magnesium (Slutsky et al., 2010) and an
nteraction of magnesium with N-methyl-D-aspartate recep-ors during brain development (Chahal et al., 1998). Miceept under daily stressful conditions can show loss of mus-le mass (Allen et al., 2010), thus showing a mind/bodyelationship. Finally, in relation to ovarian endocrinology,t has been shown that magnesium improves LHRH releasen vitro (Adams and Nett, 1979). In conditions of magnesiumeficiency, the opposite could be true altering LHRH release.
.6. The choice of magnesium for supplementation
or oral supplementation we have chosen to use an organicorm of magnesium, i.e. magnesium citrate. Using thisure magnesium preparation we have obtained satisfactoryesults. The daily dose has been 3× 1.4 mmol of elemen-al magnesium. On-going studies with patients with thyroidisease show an increase in serum levels of magnesiumunpublished results), a feature not usually seen when non-rganic magnesium preparations are given.
Several studies have been conducted with non-organicagnesium salts. In order to make them comparable to
ur approach we have calculated the amount of elementalagnesium contained in each preparation. In 1982 Dyckner
nd Wester recommended to administer 30 mmol of mag-esium sulfate (!) (Dyckner and Wester, 1982). Oster andpstein recommended up to four times 12.34 mmol usingagnesium oxide (Oster and Epstein, 1988). Using
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Athe mental number line in the mapping of life events. ConsciousCogn 2009;18:781—5.
Banga I, Szent-Györgyi AG. Preparation and properties of myosin A
agnesium pidolate, Paolisso et al. (1992) administered6.2 mmol of magnesium. In a study designed to treat legramps in pregnant women Dahle et al. (1995) administered5 mmol of magnesium citrate magnesium/magnesiumactate. Lima et al. (1998) administered either 20.7 or1.7 mmol of magnesium oxide to patients with diabetesLima et al., 1998). It is clearly evident that when usingon-organic magnesium salts, the recommended daily doses much higher than the one we have used. Experimentalata have shown a better bioavailability of magnesiumitrate as compared to magnesium oxide (Lindberg et al.,990). Experimental data has shown that a combination ofagnesium with selenium can influence magnesium uptake
Musik et al., 2000). We are currently exploring this optionor patients with thyroid disease.
. Conclusions
n this practical clinical study we have been able to identifytressors that show a yet unrecognized relation to the situ-tion of well-being in patients with thyroid disease. Thesetressors involve alterations of the musculoskeletal systems well as psychological situations. A central finding is thatf significantly decreased levels of serum magnesium. Treat-ng these two stress components and correcting magnesiumeficiency improves general well-being and ameliorates the
psychosomatic — symptom load that was initially present.e recommend the use of pure magnesium citrate, 3×
.4 mmol per day.In a situation of magnesium deficiency or increased
emand of magnesium negative consequences can arise inonnection with female reproductive function. We can spec-late that failure to recognize this condition in women withypothyroidism could aggravate the post-partum period.
The adequate treatment of hypothyroid patients pre-enting unresolved complaints is a demanding medicalask. While Western Medicine is focused on a reductionistpproach, many teachings can be derived from mind—bodyechniques. In order to reproduce our results cliniciansave to be aware of the need of expertise in endocrinol-gy, internal medicine, gynecology, manual medicine, andcupuncture and bio-energetical mind—body aspects. Thiss what we call the ‘‘WOMED model’’.
. Summary
hat was known before in this field?
Experts on thyroid disease have recognized that patientswith hypothyroidism present residual symptoms which arenot related to hormonal parameters.
These patients have been stamped as having psychoso-matic illness.
Statistical, demographic analyses based on questionnairesdealing with quality of life parameters have further doc-umented these residual symptoms.
Neither clinicians nor epidemiologists have provided anytherapeutic option for these residual symptoms. c
R. Moncayo, H. Moncayo
Considerable amount of debate on this topic can be foundin the Internet.2
What are the contributions of this study?
We have found that the so-called psychosomatic illness ofhypothyroid patients is related to physical and psycholog-ical stressors; these conditions are treatable.
The examination of patients with hypothyroidism is ahands-on situation in order to recognize the muscu-loskeletal components involved.
A simple three-point stress score is helpful in evaluatingpsychological stress.
Determination of serum magnesium levels is of cen-tral importance. Optimal levels of magnesium should begreater than 0.9 mmol/l.
Mind—body interactions in the form of stressors arerelated to low magnesium levels.
Recognition and treatment of the elements involvedrequire either improved holistic clinical skills of the singleexamining physician or dedicated team work.
We describe the intricacies of thermodynamics, noesis,Salutogenesis, resilience, bioenergetics and mind—bodytechniques in relation to this clinical situation.
Low levels of magnesium can potentially have energeticconsequences on Complex V of oxidative phosphorylationthat can affect female reproduction.
Persistence of a ‘‘psychosomatic’’ condition could aggra-vate the post-partum period and woman health as awhole.
cknowledgement
unding was provided by WOMED.
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