Keto as Adjunctive Therapy for PTSD: New Case Study

Nicole: 
It’s really well-documented that individuals with PTSD have areas of brain hypometabolism. They have higher levels of oxidative stress. They do have neurotransmitter dysfunction, more glutamate as opposed to GABA. And so, these are all things that specifically ketogenic diets target.

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a non-profit initiative of Baszucki Group, where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

Could ketogenic therapy help improve symptoms of PTSD? We’re learning a lot more about this. There have been some published case reports. There’s ongoing studies. And now, Nicole Laurent has published a case report of her own. So, if you don’t know Nicole, she’s at mentalhealthketo.com. She’s a licensed clinical social worker and therapist who specializes in ketogenic therapy and is very busy publishing case reports, data from her practice, conceptual papers.

She’s done a lot of publishing. And this particular publication that we talk about today is a pretty dramatic case report of someone with treatment-resistant PTSD being started on ketogenic medical therapy and how that changed so much in terms of her symptomatology. And so, Nicole and I get into the details of maybe why that is, what it means, what it doesn’t mean, what this can mean for further clinical practice.

So, a really interesting discussion about PTSD ketogenic medical therapy with Nicole Laurent. So, I hope you enjoy this discussion. Many of the interventions we discuss can have potentially dangerous effects if done without proper supervision. Consult your healthcare provider before changing your lifestyle or medications.

In addition, it’s important to note that people may respond differently to ketosis, and there isn’t one recognized universal response.

Nicole Laurent, welcome back to Metabolic Mind. It’s great to see you again. 

Nicole: 
Thank you, Bret. Thank you for having me today. 

Bret: 
Yeah, it’s my pleasure. I’m excited to talk about this paper that you published about a retrospective case report for ketogenic metabolic therapy for PTSD. But before we get into that, I always like to start by asking, what is a misconception within the world of psychotherapy and counseling that you wish were different?

Nicole: 
I wish that psychotherapists were able to consider better or feel more involved in the biological pillar of a biopsychosocial model of practice. Understanding how that really influences all the downstream treatment effects that they’re trying to achieve through psychosocial practice. 

Bret: 
Yeah, that’s a great answer and really sets us up well for the discussion today about how the metabolic and the biologic side of things can work together with the counseling and the psychologic side of things, as they’re not as distinct as the name might make them sound.

So, let’s get into that. So, your paper published in Frontiers in Nutrition, Ketogenic Metabolic Therapy for Treatment-Resistant Post-Traumatic Stress Disorder: A Retrospective Case Report. So, the timing of this is super interesting with Dr. Robin Engelhardt doing a pilot study on ketogenic therapy for PTSD, hearing some other case reports about this.

And it’s this concept of this transdiagnostic concept of metabolic dysfunction. So, give us sort of the background of this case and what stood out for you. 

Nicole: 
It’s not surprising because there’s actually been documented, lots of documentation, about metabolic disruptions seen in the brain in PTSD and the body metabolic disorder.

So, this is not surprising that this might be a very helpful treatment for people with PTSD that really hasn’t been considered adequately prior. But when I was writing up the case study for this, I got to go deeper into the research literature about that. And there’s like direct metabolic pathways of dysfunction seen in PTSD.

And so, this is cool and not really surprising. So, really it’s a 45-year-old woman, and we did KMT for 25 weeks. And it was really wonderful and rewarding case study to write up and to help her kind of tell her story about what happened for her. And she actually had a history of something called military sexual trauma that was part of her psychiatric history, and she experienced that in the Air Force.

And then, she also had a background in a family where there’s a lot of shame and that sort of thing. And so, she really didn’t share her trauma history through her many years of attempting to feel better until just two years before this case study was made. And so, she was really quite new with her PTSD diagnosis. But the implications of that diagnosis had been going on since adolescence and were really well-documented as part of this case study that, or this case report, that was written up.

And then, so she had that really difficult recurrent sexual trauma history. And then, on top of that, she was a nurse. And so, she was also exposed to a lot of really emotionally traumatic clinical situations that kind of continued to compound these factors for her. So, she was actually a very complicated case.

And her treatment history actually spanned, she was guessing, but it was approximately 18 years of really intensive psychotherapies trying to alleviate these symptoms that she was living with. 

Bret: 
Yeah, I think that’s an important part about this is that it wasn’t a new diagnosis, and it was the title says, treatment-resistant.

So, it sounds like she had undergone extensive psychotherapy. Were there other treatments she had tried? 

Nicole: 
Yeah, and even just thinking about the different psychotherapy treatments that she had tried, those in and of themselves were quite extensive. She did EMDR, CBT, internal family systems, drama therapy.

She was part of a peer-to-peer PTSD support group with meditation. She had gone to a psilocybin-assisted retreat. And she had even participated in different therapeutic workshops in a residential PTSD treatment program, but she wasn’t able to tolerate. She had adverse experiences trying to work through trauma in that setting, and she really only stayed for a part of the time and ended up going home.

So, this was actually useful to the case study because what it meant was that her severity of symptoms was actually documented two years prior to her starting the ketogenic diet on assessments of PTSD symptomology. 

Bret: 
Wow. Yeah, that’s pretty extensive. She had so many different types of treatments, and to still not be seeing any improvement is can be certainly depressing even more so and just disempowering.

When she came to you, what was her mindset about sort of optimism of recovery or something actually having a positive impact for her? 

Nicole: 
Yeah. It’s interesting. A lot of the people who come to see me get to see stories of other people recovering. So, I think she was actually quite hopeful, right?

That this might be something that would be really helpful for her. So, what she did was she contacted me. And just like a lot of other people who contact me, if I can’t get them in right away, they start on their own because they all do have optimism, even in spite of decades of having treatment-resistant conditions.

And so, she actually began the diet nine days before I could even get her in. And she started to experience treatment effects, she said, five days in. And so, by the time I got her baseline myself, not the historical one, she was already experiencing a little bit of symptom improvement and was already very optimistic and hopeful based on that.

Bret: 
Wow, that’s fantastic, yeah. That’s a great story that it was, she was already improving and that she was able to implement the dietary changes probably without a lot of support if she wasn’t working with you. Did she have other means of support at that time?

Nicole: 
No. So, she restricted carbohydrates down.

She started to restrict carbohydrates down. She understood she needed to do that, and she did reach ketosis before she met with me at point five. But she didn’t actually get into therapeutic levels of ketosis until we modified her diet and taught her food tracking and all the other pieces that go with it.

Bret: 
Yeah, so actually that brings up an interesting question. So, for her and in general, what are some of the things that you have to change most to help people achieve sort of a deeper therapeutic level of ketosis? 

Nicole: 
Yeah, all the things that we talk about, that you talk about with different people on Metabolic Mind.

So, sometimes people are eating higher than what we would consider a moderate amount of protein per meal, and that can lower ketone levels. Often, they don’t quite understand how many carbohydrates are in things. And just eating from a low-carb food list, for example, sometimes still keeps carbohydrates up per meal a little bit higher than they need to be for good ketosis.

I’m someone who likes to look at per meal macros. And so, there’s just these different kinds of things that we do to fine-tune when you go to get professional assistance on a ketogenic diet that they can really dial in quickly for you. 

Bret: 
Yeah, that’s a good point about per meal macros. I think that’s something that really isn’t talked about enough. That if you say, limit your carbohydrates to 30 grams per day, theoretically, that means you could have 30 grams at one meal, which may kick you out of ketosis, or certainly lower your ketone levels after that one meal as opposed to spreading them out during the day.

So, I think that is an important caveat that maybe does need to be discussed more often. 

Nicole: 
Yeah. 

Bret: 
So, all right. So, this is great. So, she was able to start a ketogenic therapy on her own, a ketogenic diet on her own. And then, you helped transition to that, to what we would call ketogenic therapy, being monitored and a deeper level of ketosis.

And then, looking at the case report, my goodness. So one score, the PCL-5 went from 32 down to two. The PHQ-9 went from 10 to zero. And the GAD-7, from six to zero. Those are dramatic changes on these score levels. 

Nicole: 
Yeah. 

Bret: 
The kind of scores that you probably would never see with almost any other therapy. And granted, it’s one person, right? It’s not a rigorous study, a randomized study. So, there’s a lot that could be, that could confound here. But still, dramatic changes and the impact on her life.

So, we can look at the scores, but what did you see that was different in her? And what was the qualitative changes that you saw?

Nicole: 
Yeah. The interesting things about things like the GAD-7 and the PHQ-9 is you can get someone who doesn’t have a very good quality of life by their own articulation of that, and they’ll still have okay scores on the PHQ-9 and the GAD-7. And I think, part of that is that those are assessments that are for psychiatric medications that are just simply looking at a lack of symptoms or a reduction in symptoms.

And the recoveries that we see with these case reports and the recoveries that we see, the scores that we see when we use much more sensitive instruments or assessment instruments are really significantly different. And so you said, the numbers that you said, those were my scores with her from when she already had started to improve after those nine days.

The historical one was actually much higher. And so yeah, it’s completely difficult to articulate the types of recoveries that individuals are experiencing with this. And so, one of the things that we did was I did an interview with her, and I captured some of the qualitative pieces of her recovery. And she shared actually some quotes that was part of the qualitative piece of it.

And one of the quotes that I just really loved, I loved them all, but one of them that I just really thought was wonderful. And that I think would resonate with a lot of people, who are looking for potential treatments for PTSD is, “I still think of some of my traumas, but they no longer have ownership over me.

The memories come up, and I am able to offer compassion to the woman I was when I experienced them.” So, that’s a really big deal. And when we do psychotherapy for trauma, that’s the outcome that we are loving and wanting and hoping for our patients. And so, this is something that she achieved with ketogenic metabolic therapy.

She didn’t continue to receive psychotherapy directly for anything specific, other than the behavioral components and the social components of maintaining the diet, and she got this result. 

Bret: 
Yeah, that is remarkable, especially considering her history, and how much therapy and treatment she had already received without achieving that result.

When we talk about ketogenic therapy, we talk about ketones as a different fuel, as being able to be a more efficient fuel, especially if someone has metabolic dysfunction in the brain, about a reduction in neuroinflammation, a change in GABA and glutamate for the neurotransmitters, and a number of different potential mechanisms.

We don’t know which one mechanism it is, which frequently from a medical standpoint, we think about a drug with one mechanism, but this has multiple mechanisms. So, what are the theories about why this would work so well for PTSD? 

Nicole: 
Yeah, so PTSD has all those things. All of those problems going on in the brain that you just talked about that have been identified potential mechanisms for why ketogenic metabolic therapy is so good for neurology and psychiatry.

It’s really well-documented that individuals with PTSD have areas of brain hypometabolism. They have higher levels of oxidative stress. They do have neurotransmitter dysfunction, a more glutamate as opposed to GABA. And so, these are all things that specifically ketogenic diets target.

I don’t think we’re going to fix mental illness with just one particular idea about one pathway. And I think that even the very early preliminary studies that are showing up for ketogenic therapy kind of suggest that’s not going to be the case. That’s not the right, that’s not the right paradigm to be addressing these issues from.

Bret: 
Yeah. Now, you also had mentioned that you helped her refine her diet to get her ketones up into more therapeutic ketosis. So, you know, we’re still learning a ton about what is the ideal window, and it’s different for each person in terms of the ketone levels and might depend on when you measure ketones.

So, how do you see that about what is a target ketone level and when? And how does that maybe change from person to person as well? Give us a little of your insight there. 

Nicole: 
Yeah, lots of people get wonderful treatment effects at 1.0 or even 0.9, 08, and we really need to have to keep that in mind. Because if you remember right, Chris Palmer’s early case reports on schizophrenia, they didn’t have a professional like me fine-tuning their macros per meal.

They got well just from a from a low carb food list doing their thing. And so, I really don’t want people to get flustered or distressed when they can’t get their ketone levels up for whatever reason. And it’s true that they just might not even need these therapeutic levels that we are thinking might be necessary.

So, I never want that to scare anybody off from it or for them to find frustration. I think people really do heal quite well. But when people have very sensitive brains or they’re really struggling, I do like to see if we can get them up to therapeutic levels of 1.5 to 3.

Some people feel really good at high levels, 3 to 4. And I think that there’s just really a lot of room for personal variability in that. And it’s so interesting research-wise that we don’t know who feels better and does better at higher ketone levels and who doesn’t yet. And so, I’m really excited for that to get figured out at some point.

But I would say that if you are someone who has done a ketogenic diet from a food list and you are not feeling significant treatment effects or you feel some treatment effects but it’s not quite what you were hoping for, it really can make a difference to play with those macronutrient ratios and just see what you can do to see where your threshold is.

Bret: 
Yeah, I think that’s very well said. Now, looking at this case report, obviously, this changed this individual’s life and was a dramatic treatment. So, of course, we want to extrapolate that and say maybe this will be the same for everybody with PTSD. But when we have limited both clinical experience and certainly research, it’s hard to make that extension.

So, do you have any concerns about other people with PTSD trying ketogenic therapy as an adjunctive treatment? 

Nicole: 
Not more so than any other diagnosis that often has a lot of medications on board as part of its treatment. So, I really don’t have reservations about individuals doing ketogenic metabolic therapy for any diagnosis. Because as you point out, there’s transdiagnostic treatment features to ketogenic diets.

My concern is always, I don’t really want anybody doing a ketogenic diet that’s on different medications without having that be watched and monitored because the reality is that there can be potentiation effects. And there actually was in this very case. A few weeks in, I think it was eight weeks in, something like that.

After feeling amazing and continuing to do well, she started to get a mood, a little bit of mood issues, out of the blue, seemingly out of nowhere. And if she wasn’t working with a professional, she might be start thinking, “Oh, the ketogenic diet stopped working. This ketogenic diet is not working for me.

I’m still broken.” All that kind of stuff would’ve come up, and it would’ve been proof that she just needed to continue on medication or whatever. But we had a conversation, and I said, “Gosh, that’s pretty weird. You were doing pretty well there for a while, and this came out of nowhere. And so, these medications that you were on.”

She was on one medication in the case study reported. And I said, “Why don’t you talk to your prescriber and see what the side effects are, and have a conversation, about this?” And she did with her prescriber, and they decided to take her off of it. And she popped right back up. So, she felt better again.

And so, someone who is not working with a professional who isn’t there to help them continue to watch for potentiation effects, or who might become more sensitive to their medications, right? Antipsychotics sometimes have to be adjusted. That’s my concern. My concern is the medications, not the ketogenic metabolic therapy.

My concern is the medications and those needing adjusted as the person starts to become well. 

Bret: 
Yeah, and often we’ll hear someone say, “I can’t find a psychiatrist who knows anything about ketogenic therapy.” And if they’re working with someone like you, like a therapist or even a dietician or a coach or somebody who is trained in ketogenic therapy who knows how to talk to the psychiatrist and communicate, do you see that as working well too, even if the psychiatrist doesn’t know anything about ketogenic therapy?

Nicole: 
Yeah. And so I’ve said it before, I really think it’s important that because it’s very difficult to coordinate with psychiatrists one-on-one unless you’re part of the medical system that the psychiatrist is working within and because of EHR and different HIPAA compliance things. And so, it’s not an easy thing to just talk directly to someone’s psychiatrist if you’re not in that medical system with them.

And so, I just really think that it’s important that people learn language to self-advocate with their psychiatrist. To learn what hyperbolic tapering techniques are. To self-educate. And I think that’s part of the empowerment of ketogenic therapies is that understanding that you are capable of self-advocating and having these conversations with prescribers.

All I do is just keep it on their radar as a potential thing that needs to be watched for. 

Bret: 
Yeah. That’s a, that’s a good way to say it. You’re teaching them how to speak the language and teaching them how to have the conversation. And so, they’re not doing it on their own, but their doctor doesn’t have to be an expert to have the conversation.

Nicole: 
Correct.

Bret: 
At least be aware of what’s going on. So yeah, I think that’s great, and you certainly serve a very important role for that. So, where can people find you to learn more about the work you’re doing? And you’re always coming out with new stuff, I think, the work that you’re doing is so impactful as an example of how it can change people’s lives, how ketogenic therapy can change people’s lives and be used as adjunctive therapy.

So, where can people learn more? 

Nicole: 
Yeah. They can go to mentalhealthketo.com. There’s an About Me page and that always has an updated record of my publications, and there’s a way to contact me there if they want to reach out. 

Bret: 
Great. Thank you for your tireless work and for taking the step to publish these and put them in the literature for everybody to see.

You’re not just keeping them to yourself. You’re on a podcast so people can hear about it, but also by putting it in the published literature, more people can access it, which is not easy to do. So, I appreciate you taking that step. So, thank you for doing that. 

Nicole: 
Yes, thank you. I’m happy to.

Bret: 
This transdiagnostic concept of ketogenic metabolic therapy is really fascinating, and we’re starting to see more and more of it, right? We started with evidence in schizophrenia, bipolar disorder, major depressive disorder. We’ve seen case reports in OCD. We’re seeing case reports now in PTSD showing that the brain kind of functions better when it has ketones, when the metabolic health is improved, when neuroinflammation is reduced and it can help with transdiagnostic symptoms.

So, we’re really starting to learn more and more about its use in PTSD. And like I mentioned, there are some studies ongoing with this. And I’m really thankful for Nicole for putting this out there, for publishing this case report. Of course, this is one individual. We can’t assume it’s going to extrapolate the same way for everybody.

But as an adjunctive therapy, certainly for someone who’s treatment-resistant. Gosh, it just really does make sense to give it a try, especially with trained or experienced clinicians. Certainly someone who can work with a psychiatrist, a prescribing psychiatrist as Nicole mentioned, with the caveats around medications and the cautions and everything.

But certainly makes a lot of sense and as the case reports and clinical experience grows, we’re offering a potential new avenue of hope for people with PTSD, especially those who have not seen the improvements they wanted with other treatments. So, another potential very exciting use for ketogenic metabolic therapy in mental health.

So, as we continue to learn more, we’ll keep reporting it here at Metabolic Mind, whether it’s case reports, whether it’s theories, whether it’s studies, but being clear about what they are and then hopefully giving individuals and their clinicians a chance to discuss this to see if it could be right for them.

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