Overcoming Limbic System Impairment with Annie Hopper
Sometimes a trauma, whether physical or emotional, can push your limbic system into a “stuck” state of fight or flight. This can lead to a host of issues, from chemical hypersensitivities or fibromyalgia to IBS or survival-related emotional states. To restore your limbic system balance, one approach comes in the form of a neural retraining program. This system targets negative triggers through conscious awareness, guided visualization, exposure therapy, the pursuit of positive emotions, and other guided protocols. If your symptoms seem aligned with this condition, you may want to consider such a program.
Dr. Michael Ruscio, DC: Hi everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m here with Annie Hopper. We’re going to be talking about ways you can help reprogram your brain in a healthier way if you’ve been under a lot of stress or trauma, for lack of a better term. As a clinician you get many biologically healthy people, but there’s a small subset of people that seem to need more of a mental retraining.
We’ve touched on this in the podcast previously, where someone biologically is healthy, but they’re stuck in this mental pattern of sickness, worry, and overreactivity. They just can’t get back to all the stuff in their life that they enjoy. And they get in a cycle of dietary restrictions, potential reactions, and reading on the internet.
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Dr. R’s Fast Facts Summary
Dynamic Neural Retraining System
- A drug free, neuroplasticity-based way to regulate an unconscious flight, fight, or fear response that has been triggered through various forms of trauma
What can cause trauma to the limbic system?
- Almost any chronic physical or emotional stress
How can this type of trauma manifest?
- Brain fog, fatigue, fibromialgia, hyper-sensitivity, chronic pain, chemical sensitivities, gut issues, mood swings, sleep issues, etc…
- Feeling like your stuck in fight or flight mode
- Questionnaire to assess
5 pillars of the DNRS program
- Recognizing limbic impairment
- Interrupting patterns of limbic impairments (POPs).
- Guided visualization
- Incremental brain retraining
- Elevating emotions during retaining
The DNRS program comes in the following formats
- Instructional video, or online video streaming, or 5-day in-person training seminar
Research on the program?
- 2 ongoing trials; one observational and one using functional MRI – results pending
Where can people learn more?
- Get help using this information to become healthier.
- Get your personalized plan for optimizing your gut health with my new book.
- Healthcare providers looking to sharpen their clinical skills, check out the Future of Functional Medicine Review Clinical Newsletter.
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I’ve very much wanted to have some therapies for this brain/gut connection. Candidly, I’ve heard of certain things like gargling and singing. And sure, I think those may have a time and a place, especially if someone’s had—as one example—a traumatic brain injury, but I think that misses a lot of what people need.
That’s been corroborated by a number of patients who have done more of this pseudo-Carrick Institute therapy. Which again, I think can be helpful for a select group. But I think it misses a larger group of patients. That’s been evidenced by many a patient who’s done those therapies, come into my office, and not reported huge improvements. Although I’m also probably seeing a select sample, because people that therapy was helpful for are probably not coming into my office!
But that’s some of the background that I’m really excited to tackle here with Annie today. So Annie, with that long welcome, thanks for being on the show today.
Annie Hopper: Well, thank you for having me. It’s my pleasure to be here.
DrMR: Can you tell people little bit about your background?
Developing Limbic System Impairment
AH: Sure. Well, I came to this line of work purely by accident, you would say. Or maybe it was meant to be, in some other grander scheme of things. I was a core belief counselor in Kelowna, British Columbia, Canada, and I had an acquired brain injury that I didn’t know was a brain injury at the time. What happened was, I was working in a building that had mold. And my office was also located next to the janitor supply room where they held all the industrial cleaners for the office.
Slowly but surely, I started to develop really weird symptoms like insomnia, anxiety, muscle twitching, brain fog, and a list of growing sensitivities. I didn’t really realize what was happening at the time, besides the fact that I knew that I wasn’t feeling well. Like many people, I went to see various different doctors, both allopathic and alternative, and eventually, I was diagnosed with a toxic overload syndrome.
Even though I did everything that I was meant to do—all the treatments, I went through everything, detoxed to Mars and back, and my system was clean—still, I was sick, and in fact, I was getting worse. Originally I was diagnosed with fibromyalgia. Then I was diagnosed with multiple chemical sensitivities, and then eventually I was diagnosed with electric hypersensitivity syndrome.
So when I had MCS, or multiple chemical sensitivities… first of all, I’d like to say that my favorite expression was, “That stinks,” because I couldn’t believe what I was smelling. I turned into this superhuman version of myself, where I could smell chemicals from a mile away. And I don’t mean strong chemicals. I mean tiny amounts of chemicals that might be in someone’s personal cleaning products or their personal hygiene products. My body and my brain were reacting as if that amount of stimuli was potentially life-threatening. Not only was I perceiving it as life-threatening, but my organs were also perceiving this as life-threatening.
So it affected my brain function, my ability to communicate. I couldn’t formulate sentences anymore, I couldn’t speak. I might actually lose my voice. It affected my digestive system. I started to develop a whole bunch of food sensitivities. That wasn’t a huge part of what I call my limbic system combo pack, but also an increasing list of sensitivities and heightened sensory perception to a lot of different things.
At its worst, it became so bad that if someone was doing their laundry and I was walking by a place where there was dryer exhaust wafting into the street somehow, I might go into convulsions. So it became really difficult to navigate my environment, any environment.
As a core belief counselor, of course, I loved working with people and I was really good at looking for patterns. Really being a curious observer, tracking thought patterns, emotional patterns, and behavioral patterns. So that skillset happened to serve me well after I developed what I call limbic system impairment or limbic system trauma.
Anyway, I started to develop all these sensitivities. It got to the point where I became homeless. I couldn’t actually live in my house anymore, which was like entering some kind of science fiction movie. That’s the only way that I can describe it. Even though logically, I knew, on one hand, that the reaction to minute amounts of stimulus doesn’t really make sense, I could not deny the fact that my body was reacting in such a severe way that I could no longer stay in that environment. So I became homeless. And when I say that, it’s not because I didn’t have money, but because I just couldn’t find a place to live anymore. I ended up camping, and then I ended up living on a broken-down houseboat for a number of months.
Yeah, I think that’s where I’ll start. There’s the start of my story.
Other Trauma Triggers
DrMR: That’s a very good starting point. So, you hit on a few things there that I think are really important to take into consideration. When someone has been exposed to some kind of trauma—in this case, we could consider this a biological trauma, but even in the absence of that biological trauma, or only in the presence of a very small amount of that trauma—you can have this heightened response. I think that’s where a facet of patients end up, as I alluded to earlier. Now, this program that you’ve developed, DNRS… can you tell people a little bit about it and what it stands for, and the intro primer into this?
AH: Sure. Absolutely. First of all, I just want to go back to trauma for a second. You’re right. You know what? It could be any form of trauma. Typically when we think of trauma, we think of it as psychological. But it’s not just psychological trauma. It could be viral, bacterial, chemical, too much exposure to EMFs. It could be psychological trauma or emotional trauma, too. Or a straight-out physical trauma like a neck injury or something like that.
So usually we say it’s a combination of traumas that lead to the perfect storm that causes or initiates limbic system impairment. Again, it could be any form of trauma where the initial response to the exposure, the stimulus, or the injury was appropriate. But then the brain gets stuck in this chronic fight, flight, or freeze response. That’s where you have patients like you do, who go through all the regular treatments, but their brain is stuck in that response. So until the brain is actually regulated again, the treatments actually don’t hold. And that’s the subset of patients that you’re talking about.
What happened with me is, after exhausting the medical system and figuring out that there actually wasn’t a treatment available to help me, I started recognizing that it was a brain impairment. It made sense to me that the brain was involved. Intellectually I knew that my body should not be reacting that severely to that small amount of stimuli. So I started to look at the brain and what was responsible for sense of smell, because that seemed like the most obvious place to look. And the limbic system in the brain is actually responsible for your sense of smell.
The limbic system in the brain is this archaic part of the brain that’s known as the feeling and reacting brain. It’s made up of a number of different structures. But what it does is, it filters the billions of sensory and emotional stimuli that are coming at us at any given time, so billions of bits of information. It basically categorizes that information into two distinct categories, threat or no threat. So if you have an injury to this part of your brain, you can imagine that stimuli that would normally be non-threatening could become classified as threatening, again, if this part of the brain is not working functionally.
So what I decided to do is become my own guinea pig and look at how I could change that area of the brain. Through a series of months and a series of exercises, I was able to act back on the brain through changing thoughts, the way that I was thinking, and recognizing thought patterns that were actually associated with the impairment itself. When your brain is changed and you’re in that hypervigilant fight, flight, or freeze response, it is absolutely going to change the way that you think.
I was tracking my patterns, like “wow, what are my thought patterns?” And if you have that fight, flight, or freeze response going off all the time, it’s also going to affect the way that you feel. Not only how you feel emotionally, but also what you’re feeling in your body. It also changes your behavior.
I started to become a curious observer of myself. What were my patterns? That was really a big ah-ha moment for me, because I thought, oh my goodness, I have become someone that I don’t even recognize anymore. I used to be a happy-go-lucky, really friendly, make-a-new-friend-every-day kind of person. Super excited about life, super positive, always looking for good stuff in my life. And I had turned into not only a very sick version of myself, but also a very depressed version of myself. I was constantly in this cycle of worry and fear, and what might happen next, and this survival loop. I was always thinking about my survival, and with good reason. I was trying to find a way to live. I was homeless, and when you have those stressors, it’s appropriate that you will be thinking about your survival on one level.
The Dynamic Neural Retraining System (DNRS)
What I realized is that my brain was stuck in a survival loop. It was in reading Dr. Norman Doidge’s book, The Brain that Changes Itself, when he was talking about Dr. Jeffrey Schwartz’s work with patients who have severe OCD—that there’s a part of the brain that isn’t functioning properly, that keeps their brain stuck in this feeling of contamination, or stuck where they’re unable to move from thought to thought—that I really recognized that. And although I didn’t have OCD, I thought, “What if the problem is actually this fight or flight response?” What if my brain is just constantly in this state of “I’m under attack, I’m under attack,” and that was actually causing all the various symptoms that I was having on so many different levels? Psychologically, emotionally, behaviorally, and in other ways. And physically.
So by interrupting the patterns that I was seeing, I could actually change the physical structure of my brain. I could change the firing of the patterns, the fight, flight, or fear responses, and also strengthen alternate neural pathways, so that my brain could reset. Once it reset, the sensitivities actually went away, and my sense of smell returned to normal, which is something that I never thought would be possible. I can only say, it was pretty cool. It was really amazing to watch my body respond to rewiring that specific area of the brain.
So basically, the Dynamic Neural Retraining System program, which is a program that I developed, is a drug-free, neuroplasticity-based way to regulate an unconscious fight, flight, or fear response that has been triggered through various forms of trauma. When you regulate the brain and reset the brain or rewire the brain, you can go from a state of survival into a state of growth and repair again, where healing can take place. That’s why we see so many people with gut issues, with sensitivity issues. Once they regulate that area of the brain, their sensitivities decrease, and they go back to optimal function again.
DrMR: Are you familiar with the work of Ashok Gupta? We spoke with him recently, and he described this as a conditioned-defense response, which sounds, of course, very similar. Perhaps just a different way of defining the same thing. I’m curious if you’ve bumped into his work anywhere?
AH: I don’t know him personally. I have heard of his work, but I don’t know of it. I know that he does focus on amygdala retraining, and the amygdala is definitely part of the limbic system. I think the way our program might be a little bit different from his is that we look at all of the structures of the limbic system and how they relate to each other, and how we can change the entire fear and threat networks of the brain. So I can’t speak to his work personally.
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Symptoms of Limbic Regulation Issues
We touched on, obviously, the importance of the limbic system. Now, I’m assuming that the way a problem with limbic regulation, if you will, can manifest, in terms of symptoms or conditions, is likely very diverse. And I’m assuming for some people it’s insomnia, for other people it might be hypersensitivity to environmental smells, as you described. For other people, I’m assuming, chronic IBS (knowing that there’s a well-documented connection between IBS and stress). Although I think that sometimes has been over-reported historically because there has been a lack of other therapies to reach to improve the condition of IBS. But clearly, that has documented, and patients will notice that under times of stress, their gut may regress.
So I’m assuming there’s this litany of presentation, and it may not consolidate to an issue in X, Y, or Z system or symptoms. But are there any indicators that may help flag for someone that this may be at play?
AH: Yeah, I think that there are a series of systems that can be involved. And like you said, it can manifest or express as a variety of different illnesses, from chronic fatigue to fibromyalgia, to chemical sensitivity, IBS, food sensitivities, chronic pain, gut issues, chronic Lyme disease (even though the bacteria for chronic Lyme may have been treated, the person still might be stuck in that chronic fight or flight state).
I think that there are different areas that you could look at to say, “Okay, could this be happening to me?” We actually have a self-assessment questionnaire on our website, really looking at different symptoms, psychologically, physically, emotionally, and behaviorally. One thing is brain fog, energy levels, chronic pain or muscle pain, heightened sense of smell or taste, or sensitivity to any sensory stimuli, that could be smell, taste, light, sound, or touch. Do they get sick when they’re in specific places? Does the smell of perfume give them a headache? Those kind of things. Sleep-related issues, as you had said before. This is an interesting one: an inability to take supplements or medications, so people become sensitive to the actual medications or supplements that would be helpful for them to take, but they become so sensitive that they can’t actually take those.
And also, the way that it affects your relationships. Your relationship to yourself and your relationship with other people. If you look at your mood, has your mood changed quite a bit? Are you stuck in emotional states that are related to survival? Like anger, worry, fear. Some people go into fits of rage for no apparent reason. Again, there’s a variety of different things that you could look at. I would look at the questionnaire on our website. That might be a start for people to recognize if they have limbic system impairment.
I think one thing that people really do recognize is, when I say this, they often say yes. I’ll say, “Do you feel like your system’s in fight or flight a lot of the time?” And they say, “Yes! Oh my goodness. I have repeating thoughts. I have repeating worries, and no matter what I do, my brain just seems stuck. It keeps repeating the same thing over and over and over again.” Usually, it’s related to some kind of worry about their health or repeating trauma, whether that is trauma from the past or your brain is projecting trauma into the future.
DrMR: Does the questionnaire that you developed give someone a score? You’re a high, low, moderate risk? What kind of information does it spit out to the user?
AH: Yeah, sure. There are 29 different questions. If you’ve answered yes to five or more, then chances are you might have a limbic system impairment, and it would be helpful for you to take the program and rewire the limbic system.
DrMR: Gotcha. Okay.
When to Treat Your Limbic System
I want to come to the program here next. But before we go to the details of the program, do you have any thoughts on if someone is thinking, “Okay, I haven’t taken certain steps to improve my gut health,” as an example (because there’s likely a large facet of our audience is interested in gut health), “I haven’t improved my diet much yet, used a probiotic, or gone through some of these simple starting point therapies for my gut, but I’m suspicious that I may also have this at play.” Do you recommend sequencing these?
So, before we go through the neural retraining program, let’s try to get your diet and some of these basics situated first, and then this would be a consideration next? Or do you feel they should be done at the same time? Do you have any thoughts on how to best incorporate this? In an ideal world, we would do every possible therapy all at once. But when people have limited time and bandwidth and resources, I always try to help them codify where to put a given therapy in a hierarchy of options.
AH: That’s a really good question, one that I don’t even know if I have a very simple answer to. I’ll tell you what my thinking process is around that.
Most people that find out about us have unfortunately been sick for a really long time, so we’re kind of the last resort. “I’ve tried everything else and nothing is working.” Then they come to us. So have they tried a lot of other things first? I would say 90% of people have tried a lot of other things first, and they end up at the program. But to speak to, is there a sequencing? It’s an interesting question, because if the limbic system is impaired and you have this chronic fight or flight response going off, it’s directly sending signals to the vagus nerve that you are unsafe. So if the gut is receiving messages that you are unsafe, then I would imagine that the gut’s going to do what the gut does to protect itself.
So would it be helpful to retrain your brain and do all of the other treatments at the same time? I would suggest, yes. Is it important to change your diet and change your gut health? Yes, it is. Would it be helpful to also incorporate brain retraining with that, so you can shut off that chronic fight or flight response, so that your body has the best ability to really heal with other treatments at the same time? I think it would be a matter of doing both at the same time. You don’t want to do one without the other.
But for a lot of people, like I said, they’ve done a lot of other treatments before they’ve come to see us. So even though they’ve addressed gut health and so forth, they’re still stuck in this chronic fight or flight state.
So not an easy answer, and not an easy question either. I wish I had the answer to that question.
DrMR: Sure, and it’s also probably difficult for you to adjudicate, like you said, because you’re seeing people who have already been through many different therapies. And I’m assuming, oftentimes, they’ve gone to several different doctors. So you’re not looking at a sample of people who haven’t even cleaned up their diet compared to people who are chronically ill. You’re seeing more people who’ve been floundering for a while, so that obviously will skew your read.
AH: Yeah, absolutely.
How the DNRS Program Works
DrMR: Tell us a little bit more about the DNRS program. I’m sure people are wondering, is this just meditation and walks in nature? Obviously there’s more to it than that. Let’s help shade in some of the gray so they know what this looks like.
DrAH: Sure. Absolutely. So what I can talk about is really the five pillars of recovery with the Dynamic Neural Retraining System. It does involve some physical exercise, which combines speech, visualization, and full body movements. But the exercises are not physically demanding or strenuous.
I’m going to talk about the five pillars of recovery, so that will give you an idea of what it is that we focus on.
The first pillar of recovery is recognizing that there is limbic system imbalance or impairment. That is really understanding how the brain has been impacted by trauma, and really recognizing how—when you’re stuck in that fight, flight, or freeze response—it’s exhibiting physically, psychologically, mentally, emotionally, and behaviorally. So it’s really understanding what the limbic system does, how it works when it’s healthy, and then what happens when that limbic system is impaired. And can you understand that, and also, does that sound familiar to you?
The second pillar of recovery is identifying and interrupting all patterns that are associated with limbic system impairment. Whether those are psychological patterns, emotional patterns, or behavioral patterns—and we call that identifying and interrupting all POPS, and POPS stands for pathways of the past—you’re stepping into that state of being the curious observer, bringing conscious awareness to subconscious habitual patterns, and redirecting the brain in moment-to-moment opportunities to help build different neural pathways.
The third pillar of recovery is completing full rounds of the Dynamic Neural Retraining System rehabilitation steps. That’s where we use guided visualization to really change the brain chemically. We want to really start producing chemicals that are associated with high emotional states, like dopamine, oxytocin, serotonin and endorphins to stop the threat mechanisms from firing so rapidly and so frequently in the brain. You really want to flood the system with all of these really good neural chemicals to stop that fight or flight mechanism from firing.
The fourth pillar of recovery is called incremental training. That’s a form of neural shaping, where we really look at strengthening alternative healthy neural circuitry. That could look like small amounts of exposure therapy to stimuli that the brain has been conditioned to perceive as a threat, and in small amounts so that the brain eventually learns that stimuli is no longer threatening.
DrMR: Almost like facing your fears.
AH: Almost like facing your fears, but in a very particular step-by-step way, yeah.
The fifth pillar of recovery is elevating your emotions during the limbic system retraining steps, and also throughout the day. You know, it’s interesting, we have a negativity bias, and everybody does. That’s part of the human condition. We naturally have a negativity bias for survival reasons and protective reasons, because we wanted to be able to see and sense a tiger if we were out in the wild. We needed to know who our predators were. But what happens with that is in limbic system impairment, not only are you stuck in that survival state, you’re not really interested in things that might bring you joy. Because that has nothing to do with survival. We want to elevate our emotional state as much as we can, not only during the rehabilitation exercises themselves, but also throughout the day, so we can retrain our brain on a moment-to-moment basis to get out of that chronic fight or flight response, and the emotions associated with that.
It’s not uncommon for people that have limbic system impairment to say, “I just don’t have access to positive emotions anymore. I can’t even think of anything positive.” That’s because the brain’s been stuck in this state for so long that they just don’t have access to it. But like training a muscle, the more you train your brain to recognize certain patterns, the easier it is to get back to those patterns.
So those are the five pillars of recovery with the Dynamic Neural Retraining System.
DrMR: How is this couched to someone? Is there an app? Is it a video? What does this look like?
AH: Yeah, good question. We deliver the program in three different formats. We have a 14-hour instructional video that’s been translated into eight different languages, so they can do it from the comfort of their own home.
We also have it available online as a streaming video option in English only.
And our gold standard is, we hold a five-day interactive training seminars in various places throughout North America and Europe, where people can come to what we call Neural Plasticity Bootcamp. For five days you’re fully immersed in learning about the limbic system, learning about limbic system impairment. Recognizing in moment-to-moment opportunities how to rewire your brain, in a setting that is conducive not only to healing, but also with a group of other people who really understand and really get you. They understand what it’s like to have limbic system impairment.
It’s a very unique opportunity. We have a few different venues in North America and Europe where we’ve sourced really highly environmentally-aware venues that meet the needs of our clients, so we can host these five-day programs.
DrMR: I’m assuming that these are created to interface directly to the user. This is not discussing a training program for a clinician to then render to the individual. I’m sure a clinician could go through and learn quite a bit, but these are meant to be user-friendly for someone with no formal training, correct?
AH: Yeah, this is for people that are suffering themselves, correct.
Research on the Dynamic Neural Retraining System
DrMR: Now, what kind of research is being done to validate this approach?
AH: There are two different independent research studies happening right now. One is at McMaster University in Hamilton, Ontario. They’ve done an observational research study by following 100 people that have taken the five-day interactive training seminar. They followed them for one year, looking at various different standardized surveys, and measuring differences in symptoms and quality of life. The research is complete. They have not published the research yet, so I can’t speak to that. However, I can say that if the research reflects what we’re seeing as individuals teaching the program, it should be really, really good.
The other independent research study is happening at the University of Calgary in Canada. We’ll be looking at doing functional MRIs on patients that have chronic fatigue syndrome, fibromyalgia or chemical sensitivities, or postural orthostatic tachycardia syndrome, and doing a baseline functional MRI. And then doing another functional MRI at about six months post-training, to see what changes in the brain are happening, and how that is affecting quality of life and health.
DrMR: In this Calgary study, are they also going to be administering some sort of lifestyle questionnaire, or tracking symptoms to see if those parallel with the MRI changes?
AH: With lifestyle changes, yeah, I think that their baseline will probably ask all of those questions. I’m not involved in the study, but I would assume that they would get a baseline study of what their quality of life is like currently, and their daily life habits.
DrMR: So you have a pre/post for a quality of life measure, but you don’t know if they are actually doing that?
AH: Yeah, I would assume that they’re going to a quality of life measure. But what they include in the quality of life measure, I’m not exactly sure of.
DrMR: Gotcha. Okay, cool. All right, so where can people learn more about the program?
AH: Well, they can go to our website, which is called retrainingthebrain.com. Really easy to remember.
Also, I published a book in 2014 called Wired For Healing: Remapping the Brain to Recover from Chronic and Mysterious Illnesses, so they can order the book on Amazon or directly through our website. The book is more about the science behind the program, not necessarily the how-to-do the program. But it’s the science behind the program, along with my own story, and various stories of people that have recovered from really mysterious and disabling illnesses through taking DNRS. The other way again, you can buy the DVDs or the streaming video program on our website, retrainingthebrain.com, or sign up for one of our five-day intensive training seminars.
DrMR: As we move to a close, are there any thoughts that you’d like to leave people with?
AH: Good question. I think the thoughts that I would leave them with are: don’t lose hope. It doesn’t matter how long you’ve been sick. When we’re talking about limbic system impairment, it doesn’t matter how long the brain has been impaired or how long you’ve been suffering, it is possible for you to recover still.
Looking at this body of illnesses from a brain perspective is a relatively new paradigm, and one that is changing the lives of thousands and thousands of people around the world. So I would say them, don’t lose hope. Go to our website, look at the success stories, and really just open yourself up to the possibility that your brain might be stuck in fight or flight. And while you should be healthy, given all of the effort that you’ve put in to taking care of your health at this time, there might just be this one piece that is the missing piece of the puzzle for you. I would say to have an open mind, and just try it. You might be surprised.
DrMR: Awesome. Well, Annie, great words to end on. Thank you very much for taking the time to speak with us today.
AH: Thank you so much, Dr. Ruscio. It was a pleasure meeting you.
DrMR: Pleasure also.
What do you think? I would like to hear your thoughts or experience with this.
- Get help using this information to become healthier.
- Get your personalized plan for optimizing your gut health with my new book.
- Healthcare providers looking to sharpen their clinical skills, check out the Future of Functional Medicine Review Clinical Newsletter.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.