Scratching Your Head Psychiatry: Practicing OUTSIDE of the Allopathic Box

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In this first lecture of his 5-lecture series for IMMH in Santa Fe, NM, Dr. Cady reviews the absolute need to get the biological basis right in confusing and confounding cases. Using real patient stories, he illustrates the blending of functional testing, food allergy testing, and hormonal interventions.

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  • The one is from 4/11
  • Scratching Your Head Psychiatry: Practicing OUTSIDE of the Allopathic Box

    1. 1. IMMH - Santa Fe, NM – September 22, 2012SCRATCHING YOUR HEAD PSYCHIATRY I:How to Think OUTSIDE the Allopathic Box… [and why you would want to…]Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Clinical Lecturer – Indiana University School of Medicine Department of PsychiatryChild, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana (c) 2012 Louis B. Cady, M.D. - all rights reserved
    2. 2. Louis B. Cady, M.D. – historical statement of support, conflict of interests• Abbott Laboratories• Bristol-Myers Squibb (Serzone)• Celltech (Metadate CD)• Cephalon (Provigil)• Elli Lilly (Prozac, atomoxetine research)• Forest Pharmaceuticals (Celexa, Lexapro, Namenda, Viibryd)• Glaxo-SmithKline (Wellbutrin)• Janssen (Concerta, [Reminyl]/ Razadyne)• McNeil (Concerta)• Pfizer-Roerig (Zoloft, Pristiq)• Sanofi~aventis (Ambien)• Sepracor (Lunesta)• Searle Pharmaceutical (Ambien)• Shire Pharmaceuticals (Adderall, Daytrana, Vyvanse, Intuniv)• Shionogi & Co., Ltd. (Kapvay)• Takeda Pharmaceuticals (Rozerem) Note: All of Dr. Cady’s presentations for this• World Link Medical conference are sponsored by Great Plains Dx Labs• Wyeth-Ayerst (Effexor, Pristiq)
    3. 3. Tech Rules…. Please turnyour phones ON (just silenced).• Shoot photos!• Tweet! ( @LouisCadyMD )• “Like us” www.facebook.com/cadywellness
    4. 4. “There are thingsknown and there arethings unknown, andin between are thedoors.”- Jim Morrison
    5. 5. Is there a need to think “outside of the box?”• Patients not getting better with all the “right” drugs.• Heroic psychopharmacology not working.• Chiropractic adjustments and nutritional interventions not working.• Dietary interventions not workiing.• ECT and TMS not working.• And the patient is still not improving despite your best care…
    6. 6. How to get the MOST out of this presentation:
    7. 7. Selecting Your Perspective• The diagnosis may be wrong.• The treatment may be wrong. – (or insufficiently potent)• The presumptive “medical stability” of the patient may be wrong.• The patient’s hormones may be out of the optimum range.
    8. 8. Cady Wellness Institute – July 2005 The Reasons:• Conventional medical practice had failed me twice.• A lot of “psychiatric cases” WEREN’T “psychiatric.”• Nobody was integrated.• Nobody was looking at ALL of the peer-reviewed literature.
    9. 9. Attention class!!www.slideshare.net/lcadymdwww.cadywellness.com/imm h/outsidebox.pdf
    10. 10. www.slideshare.net/lcadymd
    11. 11. CURRENT PRACTICE OF MEDICINE:What a patient had to say about her “specialists”:“They just monitor my degeneration.”
    12. 12. Greben’s “Seven Habits” • Empathy & concern • Warmth • Interaction • Ability to arouse hope • Expectation of improvement * • “Not to despair” Required to GET THE • Reliability & Friendliness DATA*Requires clinical depth and breadth of knowledge – as well as step-by-step logical decision making.“On Being Therapeutic” [Canadian Psychiatric Association Journal.Vol. 22(1977) 371-380.
    13. 13. Context for thinking AND practicing “outside the box”• If you don’t know it and can’t do it, who CAN locally?• Can YOU learn it and do it?• If you can’t do it (because of licensure) – who can you partner with and/or refer to?• The focus of this lecture is to make you AWARE of what can be done, not necessarily to insist that you do everything presented.
    14. 14. Consultations with “complementary and alternative” practitioners• US, 2004. 36% of US adult >18 yoa – National Center for Complementary and Alternative Medicine survey, 2004. • http://altmedicine.about.com/od/alternativemedicinebasics/a/CAMus• Canada – 1.2 million adults, or 13% of the population of Ontario. N = 32,598 surveyed. – Williams, Kitchen, e al. Alternative health care consultations in Ontario, Canada. BMC Complementary and Alternative Medicine 2011, 11:47
    15. 15. Today’s Medical PracticeChallenges – presenting in mental health settings…• Obesity, diabetes, auto-immune, inflammatory and chronic diseases increasing• Inflammatory triggers increasing• Novel viruses and infective organisms• Unresponsive/resistant infections• Weakened immune systems• GI decline/inflammation• Poor quality /foods/nutritionals• PEOPLE COMING IN NOT WORKED UP.
    16. 16. A case of depression? Symptoms at presentation:• 43 year old aerobically fit MWM competitive cyclist/ pharmaceutical rep. Drinks protein shakes (whey).• Mind and emotions: – Depression – Difficulty with memory, attention, – Short attention span – Weakness, fatigue, loss of energy• Miscellaneous: – Fatigue – Apathy/lethargy – Sleep apnea (previously reviewed) – Difficulty getting out of bed in the a.m. – Recurrent apthous ulcers
    17. 17. Classic “atypical presentation”• History continued: – Exhausted/fatigued with multiple vague symptoms for 3 years. Taking naps in car in afternoon while working. – Intermittently nauseated for last two years. MD ignored him.• Known ADD. Started on Vyvanse by family doc.• Past history: at 41 yoa – dx’ed with Rocky Mountain Spoted Fever. Tx’ed with Doxycycline – Ulcer dx by GI doc, with + h. pylori. • Rx: Macrobid + Flagyl. – “Pins & needles sensation under skin began – May 2009 (Antihistamine tried – didn’t work. )
    18. 18. Diagnostic Interventions and Trial Tx• Sleep study – non revealing• IgE food allergy possibility per dermatologist. Anti- histamine used. Sxs would stop then come back.• Soreness – consulted pain management doctor. No help.• Testim tried (low normal T) – no help.• Cholecystectomy – Sept 2009• Severe constipation Dec 2009 – went days without bowel movement• Colonoscopy – benign. Possible “small bowel bacterial overgrowth.” ABX used.• Dx’ed with possible Lyme’s – more ABX.
    19. 19. Other past dx/tx procedures:- CT brain – normal- CT abdomen – normal- HIDA scan – abnormal - (Gallbladder subsequently removed)- MRI – lower lumbar – essentially normal but with slightly bulging disc- MRI – thoracic and cervical – good- Colonoscopy & sigmoidoscopy – benign.- Muscle biopsy – “nerve damage”- Stress EKG and Stress Echocardiogram – wnl
    20. 20. More symptoms at presentation• dry/brittle skin; puffy wrinkled skin• dark circles under eyes• persistent rash with pins and needles sensations on skin• “heaviness” in legs; shortness of breath• exhaustion with minor exertion• certain foods cause ill feelings• difficulty losing weight• Needs to drink coffee to get going in a.m.• Tired 1 – 3 hours after eating• Feels faint or weak.• Rates self as overweight
    21. 21. Lab review – May 2011– Testosterone 460 {300 – 890}– % Free Testosterone 1.4%(L) {1.6 – 2.9%}– CBC shows ANEMIA • RBC 3.87 (L) {4.5 – 6.0} HGB 12.8 (L) {14 – 17} • HEMATOCRIT 37% (L) {42 – 51%}– TFT’s • TSH 1.13 • FTI 4.50 (L) • T4 thyroxine 4.9 (L) {6.1 – 12.2} • T3% uptake 36.4% {32 – 48.4$}– A.m. cortisol 10.4 {5 – 23}– Iron 103 {76 – 198}– 25-OH Vitamin D low (outside lab)
    22. 22. Working hypotheses, treatment• Anemia – etiology unclear• Hypoadrenia• Rule out post-viral fatigue syndrome• Subclinical hypothyroidism• Possible symptoms of low testosterone• Possible IgG food sensitivities (dairy?)• Probable candida (by history)• Low Vitamin D• History of depression and ADHD – on tx.• History of Lyme Disease – allegedly tx’ed.
    23. 23. Initial treatment planning• Consider transition to Armour• Consider testosterone• Dairy free diet. (based on history)• Start Xymogen IgG 200 DF• NutraProbiotics – one daily• Get more labs, including IgG
    24. 24. Interventions and follow-up• 6/14/2011 – Start NO DAIRY DIET. Baseline medications (incl. Lexapro, T4), continued. Probiotics. Minimize exposure to brewer’s yeast.• 6/30/11 – better energy. “allergic shiners” gone. (Labs reviewed) – Rx: started DHEA – 50 mg SR; 5HTP – up to 100 mg daily for documented low serotonin. Slight increase in thyroid Rx. Start Nystatin.
    25. 25. Most relevant labs (ordered before appointment):
    26. 26. Other interventions and current status• Testosterone cypionate – 100mg cc IM q wk.• Armour thyroid – (needed it for a while), then didn’t• Supplements – in addition to high potency MVI twice daily (including Zinc)… – Adrenal supplementation – 2 twice daily – DHEA 50 mg SR daily – B-12 – liquid – Vitamin C – 2500 mg per day in 4 – 5 divided doses – Vitamin D – 5,000 IU daily – IGF2000 DF (Xymogen) – one scoop periodically. – Calcium and 5HTP – Coenzyme Q10 400 mg per day• Continue 70 mg Vyvanse and 20 mg Lexapro
    27. 27. Zinc & Testosterone• Low Zinc- associated with low testosterone – Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto, W.Y. (2000). Low serum testosterone level as a predictor of increased visceral fat in Japanese-American men. International Journal of Obeisty and Related Metabolic Disorders, 24, 485-491.• Per USDA, 60% of US men between 20 – 49 years of age do not get enough.• Fast food = low zinc = testicular tissue inflammation = dec. testosterone – El-Sewedy MM et al. J Pharm Pharmacol. 2008 Sept;60 (9):1237- 42.
    28. 28. Low Vitamin D linked to depression[Muhlestein JB et al. Am Heart J, 2010; 159(6):1037-43. (citation from Dr. Shaw)• 7,358 patients >/= 50 yoa with CV diagnosis and NO HX of depression• “Vitamin D levels were significantly associated with an increased risk of depression, compared with optimal vitamin D levels.”• Optimal level: > 50 ng/ml – Normal 31 – 50 ng/ml – Low: 16 – 30 ng/ml; “very low = < 15 ng/ml
    29. 29. 8/1/2011 follow-up: strict dairy free diet• “Some days I don’t feel as hot in terms of energy level. But it has improved. I’m thinking more clearly.”• Lost 8 lbs (by desire)• Rode bike in extreme heat on Sunday for 1 hour.• “I’m able to get out and do things that I feel like doing –working around the house, hanging around my family, and going fishing.”
    30. 30. 9/13/2011• Went out and rode three hours on his bike for first time in years. – “But I came home and crashed.”• Working full time as rep. No longer napping.• Lyme disease diagnosed based on new labs. Treatment started.
    31. 31. 9/13/2012• Vigorous. Working around the house.• No limit to activities (or distance for his rides)• Career going well• Biking going well• Enjoying life.
    32. 32. Do we really need all thosesupplements and vitamins??? B12, Magnesium, Zinc, fish oil…
    33. 33. Modern Medicine’s Paradigm:Two Standard Deviations – “if you are not sick, then you must be well.” “NORMAL” OPTIMAL? OPTIMAL
    34. 34. Definition of “normal labs”: “When your lab values are as crappy as everyone else’s.” - Neal Rouzier, MD (World Link Medical Seminar II – Spring 2011)
    35. 35. “There are more things in Heaven and Earth than are dreamt of inyour earthly philosophy, Horatio.” - Hamlet
    36. 36. S N O TI CA BODYD IN M
    37. 37. Let me tell you some more stories.Once upon a time….
    38. 38. The Case of the Phrustrated Pharmacist…• 58 yo married Caucasian R.Ph.• CC: “Seeking definitive diagnosis and appropriate treatment to improve my energy level and mood instability. [sic]”• Active issues: – Concentration problems – Weight gain – “feeling like a slug” – “no sex drive” - “for years”. Problem in marriage.
    39. 39. “Relevant” symptoms• Lack of/loss of interest in things• Low energy• Appetite increase• Feelings of worthlessness• “memory problems” (Concentration??)• Frequent negative thinking
    40. 40. Other interesting data:• Multiple speeding tickets. – “My worst one was not that long ago, but the guy gave me a break or I would have lost my license – I was going at least 30 mph over the limit.” – Has had 4 – 5 speeding tickets. “I’ve had a heavy foot.”• Previously diagnosed with ADD by family physician
    41. 41. Medications at presentation:• Effexor – 37.5 mg XR one in the a.m.• Ritalin LA – 20 mg in the a.m. for ADD• Levothyroxine – 0.1 mg “with everything else in the a.m.”• Simvastatin 20 mg – in the a.m.• FemHRT, Flonase, Celebrex ( 200 mg daily x 5 years)• Pepcid – 20 mg daily
    42. 42. Historical data• Excellent student in high school• Excelled in pharmacy school• “hate it that my memory is getting bad.”• “It’s true that I do cope with shopping.”• Recalls ADD symptoms since childhood. Diagnosed self based on review of a checklist of ADD symptoms from a patient’s mother.• Having muscle aches and cramps. (Statin?)• Presents with lab drawn by primary doctor – Jan 2010 of total testosterone of 10 ng/dL (!!!)
    43. 43. Mental Status Examination:• Alert and pleasant, but depressed• Stressed about her fatigue and lack of focus• Rating Scales: – Showed 5/9 symptoms of depression – DSM-IV, ADHDRS , Jasper-Goldberg, Amen Clinic 6-type ADHD questionnaire – all consistent with significant INATTENTIVE SYMPTOMS.• Notes NO LIBIDO.
    44. 44. Diagnoses, workup, treatment• ADD - inattentive type• Hypoadrenia (probable)• History of MVA x 2 with mild HNP• Hyperlipidemia – wrong dosing – change to HS• Hypothyroidism – change T4 to empty stomach• Menopausal – with unknown levels of most hormones; certainly needs more T – started at 1 mg up to 4 mg topical per day after recheck• TESTING: conventional labs ordered• Patient told to GET MAMMOGRAM
    45. 45. Lab testing – R.Ph. 04/26/2010• FSH 77.2; LH 44.5 = menopausal• Estradiol 14 {<89 = p.menopsl}• Testosterone 11 {“6 – 25”}• DHEA-S 51 {26 – 200; Cenegenics = 350 - 500}• TFT’s – TSH 1.47 {0.55 – 4.78}| – Free T4 1.28 {0.80 – 1.76} – Free T3 2.8 {2.3 – 4.2} – Elevated TPO and Thyroglobulin Ab Started on 1mg up to 4• Lipids: mg of Testosterone TD /d – Cholesterol 225 (H) {<200} – LDL 151 (H) {<130}
    46. 46. One month follow-up 5/18/2010• PAP done. Mammography – not yet.• Got labs done (reviewed).• Hadn’t consistently gone up on testosterone• RX: – Added Cytomel to T4 - 5 MICROgrams SR up to 10 MICROgrams SR q a.m. – DHEA – 25 mg extended release (GNC) q a.m. – INCREASE testosterone up to 4 mg per day• New labs in 6 weeks.
    47. 47. 2nd follow-up 7/13/2010 – on 5 MICROgrams SR Cytomel• Hugged me upon encounter. Thanked me for “transforming my life.”• Mind is working dramatically better• Passed on-line testing the first time, compared to peers, who did not.• Energy is better.• Has started asking her Medicare patients about complete TFT’s • Stress was from “performance problems and thinking I was losing my mind.”• No labs yet due to expensive colonoscopy.
    48. 48. Can you change ADHD symptoms without changing ADHD meds?Patient presents on ongoing, BASELINE dosing of:-Ritalin – 20 mg LA in the a.m.-Effexor – 37.5 mg XR in the a.m.Now on: 5 MICROgrams Cytomel SR (w/ T4) + 4 mg TestosteroneADHD Ratings - April ADHD Ratings - July • DSM-IV: 6/4 • DSM-IV: 2/0 • ADHD-RS: 27/20 • ADHD-RS:11/12 • JGRS: 44 • JGRS: 13
    49. 49. Lab testing – R.Ph. 11/04/2010• FSH 77.2; LH 44.5 = menopausal• Progesterone <0.2 {menopausal}• Estradiol <20 {menopausal}• Testosterone 11 {6 – 25}• DHEA-S 65 {26 – 200}• TFT’s – TSH 0.29 {0.55 – 4.78} – Free T4 1.02 {0.80 – 1.76} – Free T3 2.9 {2.3 – 4.2} – but feeling good! – Elevated TPO and Thyroglobulin Ab• Lipids: – Cholesterol 225 (H) {<200} – LDL 151 (H) {<130}
    50. 50. Follow-up 2/11/2011• Libido: ““Better than it was, but not passionately horny all the time.”• Ongoing back pain – sent to D.C. colleague• Cytomel changed to one 10 MICROgrams SR dose in a.m. with her 0.1 mg T4• Not using Testosterone consistently – told her to do so• Started Pregnenolone – 100 mg SR “for memory.”
    51. 51. Follow-up 5/10/2011• Progesterone 20mg/cc, compounded, transdermal, started.• Continued on testosterone (2 X/wk) and Cytomel SR (10 ug) + 0.1 mg T4 + 100 mg Pregnenolone• Ritalin LA 20 mg (getting “wear off” and “slump” at 6 hours); Effexor – 37.5 mg XR• Craving carbs – started on low dose Topirimate DSM-IV ADHD-RS Jasper- Goldberg3/ 4 as child6/4 – intake 4/2010 27/20 - intake 44 – intake2/0 – 7/13/2010 11/12 - 7/13/2010 13 - 7/13/20100/0 – 11/11/2010 11/12 - 11/11/201 15 - 11/11/2010/0 - today 10/9 - today 19 - today
    52. 52. Phrustraded Pharmacist Follow-up 2/28/2012• On weight watchers: has lost 24 lbs.• “I’ve got my organizational skills back. Things are back together again.”• No more energy sag in the afternoon. (Note also the good diet).• Enjoying life. Participating in Corvette Club with her husband.
    53. 53. 8/28/2012Photo of the happy“phrustrated pharmacist”
    54. 54. 163.688 children and adolescents (86 studies)14,112 adults (11 studies)Inattentive subtype most commonDx similar irrespective of parent or teacher rating, or a best estimatediagnostic procedureKids: {5.9 – 7.1%; young adults 5%}
    55. 55. 165 respondents out of 259 children in British ColumbiaADHD diagnosed in 131 (out of 165) from 259 eligible.68.7% having comorbid psychiatric disorder: 51 kidswith LD, 45 with ODD/Conduct DO, 27 – other dxFINDINGS: “ADHD has a significant impact onmultiple domains of health-related quality of lifemeasures: in role function, behavior, mental health, andself-esteem.”
    56. 56. The Disorganized Daughter – intake 7/18/12• 29 year old married Caucasian female – ref in by family and Dad.• “I don’t even know where to begin. From puberty on, I’ve struggled with quite a bit of depression.”• Per mother: “severe insomnia, mood swings, periodic fits of rage followed by sadness/crying; difficulty concentrating; flight of ideas, trouble managing daily activities; little impulse control”
    57. 57. Disorganized daughter – more history.• Significant history of alcohol and opioid abuse and dependence. (now on ultra low-dose Saboxone) Also abused Ambien. – “Used them so I could SLEEP.”• History of bipolar in the family• Hospitalized in March 2012 due to “I quit sleeping and began to hallucinate.”• History of not sleeping well and having to use opioids to self treat.• Very active child.• “No diagnosis of ADHD” ever made.
    58. 58. DX/RX – 7/18/20121. Severe bipolar disorder, rapid cycling type (with sleep deprivation and psychosis)2. Opioid dependence – (on saboxone taper)3. History of severe PTSD4. POSSIBLE ADHD5. LABS ordered6. RX: – started on 3 mg of Invega, then 6, then 9 as tolerated. – Referred for therapy once bipolar settled.
    59. 59. Rating Scale review – 7/18/2012 Results scoringDSM-IV 1/3 – as child 9/9 = max (I/H); 6 = dx 6/8 – now as adult (same)ADHD-Self Report 20/33 36/36 = maxJasper-Goldberg RS 94 0 – 120 = range; 70 is cut-off for likely dx of Adult ADHDAmen Rating Scales 9 symptoms on Inattentive (6 symptoms required for diagnosis) 9 symptoms on (5 sxs required for diagnosis) overfocused 6 symptoms temporal lobe 6 symptoms required for diagnosis subtype 7 symptoms “limbic” (5 symptoms required for) 10 symptoms “ring of fire” (5 symptoms required) subtypeFatigue Severity Scale 56 36 is cut off (63 = max)Epworth Sleepiness 22 10 is cut off (24 = max)Scale
    60. 60. Two follow-ups• 7/31/12 – used the Invega, got overly sedated, got better, stopped it – got worse. Sleep disrupted. On it for two days prior to seeing me and feeling better.• 8/28/2012 – dramatically better; in therapy – On Invega 6 mg per day +Benztropine 1 mg three times daily. Start Lamotrigine with plan to cross titrate. – Labs showed anemia with very low iron – Has gained 0.8 lbs. – Dx’ed with subclinical hypothyroidism – started on Armour – Started on PNV with Fe and DHA – Viewed as stable enough to take Quotient test
    61. 61. Follow-up – disorganized daughter• 9/18/2012 – absolutely stable. Feeling great.• Concerned about weight increase (5 lbs)• On Invega at lowered dosage of 3 mg + 50 mg Lamotrigine per day. – (had sleep walking)• DHEA – 25 mg ER (GNC) – 1 in a.m. + ¾ grain Armour in a.m. Now has more energy and is getting things done.• Quotient test reviewed…. (done before appt)
    62. 62. BADNESSGOODNESS
    63. 63. STATS:•ATTENTIVE 7.5% (!!!) of the time•Impulsive 47.5% of the time•Distracted 32.5% of the time•Disengaged 12.5% of the time
    64. 64. Patient’s response to the Quotient results:• “Wow, that’s really bad isn’t it?!”• Asked if she had had severe problems with attention in school.• “Well, there’s actually something I’ve never told you…”
    65. 65. More history, more treatment• “I actually used cocaine [therapeutically] before school( in high school) to concentrate.” – Set the curve in all of her finals in her junior year. – Stopped it in her senior year – Used opioid (Lortabs) throughout college to study and focus. (“It made me awake and helped me do stuff.”).• Now concerned about her ability to focus.• Brother, in law school, recently dx’ed with ADD. On Adderall. Doing much better.
    66. 66. A question and treatment• “Would one of the things about ADHD be that when I sit down with my kids I can’t even complete a single ‘craft’ activity? My husband has to finish it. I can’t even do it.”• RX: – Increase Lamotrigine to 100 mg per day – Stop Invega 3 mg in two weeks. – Start Vyvanse at 10 mg, going up by 10 mg every day or so to 50 mg. (Aliquot;Goldilocks) – Increase Armour to one grain; cont DHEA 25 mg
    67. 67. Key take-aways from this case• Don’t let a substance abuse disorder give you a constricted field of logic.• Affective disorders and ADHD can coexist.• Frequently ADHD’ers have used illegal drugs or tried their kid’s stimulant.• Avoid Puritanical blame/self-righteousness: – Many ADHD’ers (and affective disorder patients) fall into alcohol, marijuana, and other drugs in an attempt to self-treat• Treat the primary problem first.
    68. 68. The Accidental Toxic Metals Test• 7 year old biracial child. Dx’ed with ADHD before appointment.• Serious reactions to stimulants.• Chronically thin, but “eats as much as my fifteen year old.”• Lives at home with mother and father (who works at a smelter)• Mental Status Examination: obviously hyper. Chatty. Somewhat obnoxious.• Psych testing – normal IQ
    69. 69. Hair analysis (instead of Organic Acids) done d.t. staff error!• Later learned of clothes washing and bathing practices, and derioration of child from early development to present
    70. 70. The Story of Alan• 2/24/2010 – “ADHD hampers his ability to focus and comprehend information. He becomes overwhelmed. Lacks confidence in reading. Teacher believes he is capable.”• Past history: “a busy child. “Couldn’t keep him in a chair.”• ADHD dx in kindergarten. Multiple Rx since, incl. Abilify• At presentation: – 20 mg Adderall XR in a.m., 3 mg Intuniv in a.m., 5 mg Abilify at 4 pm. – “Heart is racing” for two months. – Hx of stimulant rebound and having to push the dose – Stools like tar since starting on Abilify.• Rating scales: – DSM-IV 9/8 before meds; DSM-IV 9/4 ON meds
    71. 71. Treatment summary and new developments• Medications adjusted. Stimulant lowered and L-tyrosine started with it (inc. to 1 gram twice daily ). – Changed to Concerta + Ritalin (a.m.), Intuniv, Risperdal, and Depakote (250 mg 3x/day)• 11/9/10 and 12/6/10 – “meltdowns” at school. States “I am going to KILL you,” when he is upset. Kicking the table at school and not looking at the teacher.• OAT test and IgG Food Allergy panel ordered.
    72. 72. December 7, 2 010
    73. 73. Organic acid testing – 12/23/2010Pertains to energy production, Kreb cycle, B vitamins, CoQ10, Mg
    74. 74. Interventions• 1/5/2011: – School insisting he is “autistic” (meltdowns) – At appt. told to remove wheat, peanuts, and milk from diet – Started on CoQ10, B-50, ALA, Vit C & E• 2/8/2011 – Alan - “for the first time I think the medicine is getting right.” (no changes made to Rx). Barlean’s Lemon Zest oil added.
    75. 75. Winding up of case• 4/1/2010 – five weeks of “awesome behavior” at school with “no blow-ups whatsoever.” – “The school authorities are amazed.” – Won STUDENT OF THE WEEK (!!)• 5/31/2011 – concluded school year; no blow-ups.• 8/30/11 – some blowups, but not the “explosive kind like he had last year.”• 12/21/11- scored “distinguished” in math and “proficient” in reading. (continues supplements and diet)• 2/17/2012 – “Tired.” RX: lower Concerta from 54 to 36 mg• Having more meltdowns at school. New labs ordered.
    76. 76. IgG results – 3/29/2012
    77. 77. - Started on Nystatin,compounded, liquid – upto 50,000 IU three timesdaily. Also Probiotic.- ELIMINATE MILK &WHEAT
    78. 78. Progress! Original IgG 3 7 2012Repeat IgG testing 06/28/2012
    79. 79. Organic acid test – 6 26 2012• Arabinose c/w candida• All B-vitamin markers improved• Coenzyme Q10 high normal• HVA, VMA, 5HIAA – all increased.• Vit C low but c/w water solubility and a.m. spec.
    80. 80. Alan – conclusion 7/31/2012• Concluded school year well.• “Was more interactive and playing on the playground.• Went up on state testing 17 points in reading. At grade level in math.• Playing outside more, riding his bicycle.• Vitamin C increased 500 mg twice daily• Start on Curcumin/turmeric for inflammation• STABLE. See back 9/30/2012.
    81. 81. A case of near catatonic depression: G. Photos of all patients, even though used with permission, have been removed from this presentation on the internet
    82. 82. Gerladine: history• 42 year old WF in committed relationship with SO. Previous severe depression.• “Depression gradually coming back.”• Previously admitted to local psych hospital, diagnosed with “bipolar” and put on lithium.• History of severe trauma as a child.• Incapable of working with her therapist.• Near catatonic. Has considered ECT• Masked facies. Shut down. Nearly suicidal.
    83. 83. Medical issues – in addition to depression• Known – Menometrrorhagia with Fe deficiency anemia • Had to have an iron infusion 3 years ago. – Mild symptoms of OSA; previous poor w/u – Obesity (with food cravings) – Severe ADHD symptoms (Quotient) (w/ history)• Likely – Hypoadrenia – Rule out hypothyroidism – Probable drop in testosterone – Rule out return of iron deficiency anemia.
    84. 84. Labs drawn following intake• CBC – RBC 3.70 (L) – HgB 10.3 (L) {12 – 15} – Hematocrit 32.6 (L) {36 – 45%} – MCHC 31.6 gm/dl {32 – 36} – Reticulotcyte immature frac 0.47% (H) {0.16 0 0.36}• Iron studies: – Ferritin 3 (L) {11 – 307} – Serum iron 80 {28 – 170} – TIBC 599 (H) {261 – 478} – % Fe Saturation 13.4% {12 – 57}
    85. 85. Hormone labs post intake• Glycemic studies – Glucose 95 {70 – 100} – Insulin 24.9(H) {2 – 23} – HgBA1C 6.4% {4.3 – 5.9}• Hormones – Total testosterone 25 {9 – 55}} – Free testosterone 2.4 ng/dL {1.1 – 5.8} – Testosterone, bioavail 6.6 {2.8 – 16.5} – DHEA-Sulfate 110 {32 – 240}
    86. 86. Meds at intake and follow-upPresenting meds – 11/16/11 Rx Adjustments – 2 mos.• Lithium 450 mg 2x/d • Tapered off Lithium• Bupropion – 300 mg XL • Bupropion – 450 mg XL – (“for years”) • Cymbalta – 90 mg• Cymbalta – 60 mg (never • Provigil 150a.m./100 pm higher) • Lunesta – 3 mg• Provigil – 100 mg 2x/d • Nexium – 40 mg• Lunesta – 3 mg (not • Abilify – 5 mg bedtime working consistently) • Focalin – only on 5, then 10• Nexium – 40 mg (1 yr) mg XR • DHEA- 25-50 mg SR (**) • Testosterone -2 – 4 mg TD
    87. 87. Jan 2012 – not much better• Still off of work & depressed. Concentration still poor. Having to “pay extra attention” so she can drive correctly.• Might get fired from work if not better.• Has seen hematologist; s/p iron infusion• Evaluated for TMS & tx started• New RX: – Progesterone 50 mg SR at bedtime (sleep) – Cytomel – 5 MICROgrams 2x/d (“feels more energetic”
    88. 88. Follow-up 2/21/12• Low Vitamin D level found on lab (14) – started Tx between last appt. and this one.• Also ¼ grain Armour thyroid added.• Therapist: “This is the best I’ve seen you in two years.”• “The first week I haven’t gained weight.” Not wanting to eat as much.• Journaling daily.• Concentration definitely improved.• RX: Cytomel tapered and Armour increased
    89. 89. Geraldine – 3/12/12• 3/12/12 – Has returned to work. Peers tell her that she “looks different in the eyes.” – Sleep has improved. – “A miraculous Wednesday – 4 ½ weeks into TMS – when “everything seemed to improve.” – Lost 2.2 lbs in the last 3 weeks.• 4/19/12 – Depression in full remission. Looks well.
    90. 90. Weights and drugs – 6/28/12Relevant weight hx Nausea• 2/21/12 - 252.6 lbs • Bupropion lowered to 300 – the first week she hasn’t mg XL gained. • Focalin XR decreased to• 3/12/12 - 250.4 lbs 20 – 25 mg XR – (Topirimate added)• 6/11/12 - 220.8• 6/28/12 - 2149/10/2012 – doing great. Dealing with stress in her life withbreakup with SO and move to new house. Coping well.
    91. 91. Photo of patient G. on her motorcycle September 9, 2012 Photo used with patient’s permission
    92. 92. Teaching points:• Imperative to get ALL the diagnoses RIGHT, and to not miss any (including medical).• Don’t reflexively “blame the patient” for failure at weight loss. – (women with metabolic syndrome, low DHEA, and low thyroid can’t just ‘lose weight’)• Even TMS is not likely to work adequately without stabilizing the biological platform.• Incredible change and improvement are possible when both medical/hormonal stabilization accompanies accurate psychiatric treatment.
    93. 93. The case of Michael• 53 yo MWM ref by pastor• “I’ve been trying to Photo of patient on do a good job since motorcycle with sword I’ve been saved. My family and church think that I’m dangerous and trying to get martyred.”
    94. 94. CURRENT history• Three months prior to intake, “received a revelation” about the way he was living.• He determined that with his name, Michael, he was to function as an angel of God and warn people about the end times (accompanied with his sword on his motorcycle).• One month prior to intake, had words with police officer; next a.m. 10 police took him to local psych hospital for eval.
    95. 95. • Kicked out of high school d.t. racial violence• Parents: “difficult to control” as a child• “Problems with his temper” since childhood• Began drugs at 13 – 14 yoa• 21-22 yoa – “I was running around with a shotgun thinking I was Billy Bad Ass.”• Robbed a local license branch. Prison for 5 years.• Previous heavy drug use, incl. K-2 (smoking it)• Had MI while driving truck 4 ½ months ago.• Implantable defibrillator (+ CABG x 3 and heart valve replacement) Now can’t drive. Depressed.• Went to church on Easter Sunday. Selling 5 – 6 lbs of “dope” per week. Converted. Changed.
    96. 96. Family Psych History:• Father – violent• PGM – “the wild one” – would physically slap people• Sisters – 3 out of 4 involved with drugs, all clean now• Oldest sister – “the hoarder” – Family had to pay $12,000 to haul 100 cubic tons of junk out of her house. – Then she did it again. Now living in hotel• NO Family history of bipolar
    97. 97. Mental Status Examination:• Tall, intense man – mustache and stubble. Coherent.• Wearing baseball white cap with a cross hand- drawn on the front and labeled “White Knight.”• “I don’t think Batman has anything on me; he’s Hollywood but I’m the real deal.” “I can’t do anything about this – it’s a revelation from God.”• Re: the sword – “the police were kind of upset about it, but it’s legal and there’s nothing they can do about it.”• Notes that God speaks to him from within, “but not in a wacky way.” Somewhat circumlocutory.
    98. 98. Rating Scale review – 8/3/2012 Results scoringDSM-IV 6/8 v– as child 9/9 = max (I/H); 6 = dx 6/6 – now as adult (same)ADHD-Self Report 13/17 36/36 = maxAffective 8 symptoms GAD; 5 “Worry + 3 is GAD.” 5/9 for symptoms of depression depressionAmen Rating Scales 7 symptoms on Inattentive (6 symptoms required for diagnosis) 10 symptoms on (5 sxs required for diagnosis) overfocused 10 symptoms temporal 6 symptoms required for diagnosis lobe subtype 7 symptoms “limbic” (5 symptoms required for) 12 symptoms “ring of fire” (5 symptoms required) subtypeFatigue Severity Scale normal 36 is cut off (63 = max)Epworth Sleepiness normal 10 is cut off (24 = max)Scale
    99. 99. Relevant recent history:• VPA – 500 mg ER – 4 at bedtime when originally hospitalized. – Made him “drunk.” Stopped it.• Then started on Seroquel XR 50 mg. Did NOT work. – “He was running around all hours of the night.” – Actually more disinhibited. – Had sword on his bike during this time.• Wife had him ED’d on 7/16/12.•
    100. 100. Diagnosis????• Bipolar, manic? ADHD? GAD?? Depression? OCD? Low serotonin state?• My impression: – ADHD – lifelong; currently MJ self-treating – History of polysubstance abuse and dependence; unknown residual effect of K2 – Meets criteria for GAD and depression – OCD’ish? Obsessive. Sister a severe hoarder. – Doubt bipolar. (51 yoa at onset.)
    101. 101. Treatment and follow-up• Viibryd – 2.5 mg (1/4 of a 10 mg tablet) as test dose, then ½ x 4 – 5 days, then one tablet. Go up in sample pack as tolerated.• Then, Focalin – 5 mg XR – start with one in the a.m. As able, increase to no more than 4 capsules• See back – three weeks.
    102. 102. Treatment and follow-up 9/5/2012• “Whatever you have him on is working – the last two weeks have been wonderful.”• “He has lost that ‘being confrontational and argumentative.”• On 40 mg of Viibryd – “I settled down and calmness came over me.”• On Focalin 5 mg XR – focus has radically improved. – “Able to cut down my weed.”• General: appetite improving. Sleeping well at night.
    103. 103. ADHD rating scale changes in three weeks.Patient presents on ongoing, BASELINE dosing of:-Viibryd – 40 mg-Focalin – 5 mg XR dailyADHD Ratings – 8/3/12 ADHD Ratings – 9/5/2012 • DSM-IV: 6/6 • DSM-IV: 0/0 • ADHD-RS: 13/17 • ADHD-RS:11/11 • JGRS: not done • JGRS: 14
    104. 104. Key learning points from this case• Avoid the “easy”, obvious diagnosis.• Respect the concept of “executive dysfunction” with ADD (as well as cingulate gyrus hyperactivity with obsessionality and low serotonin)• Know characteristics of mental disorders• “mood swings” and manic like behavior does not equal a de facto diagnosis of bipolar• Good people can use MJ/Rx to “self-treat”• Good people can do bad things with ADHD.• Avoid being judgmental• Start dosing LOW. Educate patient.• Can normalize patients in one month.
    105. 105. So what the heck am Isupposed todo with this stuff?
    106. 106. What I would like for you to get out of this talk…1. Acknowledge that you are the best.2. Expand your paradigms!3. Too much of a good thing is NOT wonderful.4. Know your stuff: 1 out of 20 (minimum) of your adult patients will be ADD/ADHD.5. Find colleagues to partner with: Doctors of Chiropractic and Naturopathy. Nutritionists.6. “There is no substitute for victory.” - Gen. Douglas MacArthur7. MUST deal with the biological no matter HOW GOOD you think your drugs are!
    107. 107. “But my patients don’t know about this and aren’t asking for it….” “It’s not the consumers’ job to know what they want.” - Steve Jobs
    108. 108. Questions for you after this presentation and weekend…• If not me, who?• If not now, when?• If I am too afraid to act, why?• What can I do?• Is is acceptable to not do all that is required to get the patient better?
    109. 109. “If you’regoing to bethinkinganyway, youmight as wellthing big.”- DonaldTrump
    110. 110. Perhaps the ability not only to acquirethe confidence of the patient, but todeserve it, to see what the patientdesires and needs, comes through thesixth sense we call intuition, which inturn comes from wide experience anddeep sympathy for and devotion tothe patient, giving to the possessorremarkable ability to achieve results. ...William J. Mayo, 1935
    111. 111. Contact information: Louis B. Cady, M.D. www.cadywellness.com www.indianaTMS-cadywellness.com Office: 812-429-0772 E-mail: lcady@cadywellness.com 4727 Rosebud Lane – Suite F Interstate Office Park Newburgh, IN 47630 (USA)

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