The physician in spite of himself syllabus 09 22 2013

4rth Annual MMH CONFERENCE – Chicago, IL.Sunday, September 22, 2013

THE PHYSICIAN IN SPITE OF HIMSELF: The Pathway Toward Enlightened, Integrated & Holistic Practice

Louis B. Cady, MD – CEO & Founder – Cady Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Wellness Institute

Continuing Medical Education Commercial Disclosure Requirement for Louis B. Cady, M.D.

I, Louis B. Cady, MD, have the following commercial relationships to disclose:•Speaker honoraria received from:

• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX

•Speaker’s bureaus (active) for:• Forest Pharmaceuticals, Sunovion, Shionogi

•Historical data – speaker’s bureau for Bristol-Myers Squibb, Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil, Pfizer-Roerig, Sanofi!~aventis, Sepracor, Shire, McNeil, Takeda, Janssen, Searle, Shire, Takeda, Wyeth-Ayerst

Le medicin malgre lui – Moliere, 1666

Microsynopsis: Sgnarelle – an alcoholic woodcutter forced into posing as a doctor who becomes rich and respected.

“If you can only read one article in your entire career at Mayo on psychotherapy, read this one.”

- John Graf, MD

“If you can only read one article in your entire career at Mayo on psychotherapy, read this one.”

- John Graf, MD

Greben, S. Can Psychiatr. Assoc Journ. Vol 22 (1977): 371-380

“On Being Therapeutic”“On Being

Therapeutic”

Psychodynamics and functional medicine

• Some therapists stand out as uniquely effective.

• Academics are no better.

• “Every potential therapist must have a floor and a ceiling to his therapeutic capacity.”

• Some gifted therapists are able to say why they succeed; others can’t explain it. “A great deal of what they do ‘right’ is intuitive.”

“On Being Therapeutic” - Stanley Greben, MD [Canadian Psychiatric Association Journal. Vol. 22(1977) 371-380].

Greben’s “Seven Habits”• Empathy & concern

• Warmth

• Interaction

• Ability to arouse hope

• Expectation of improvement

• “Not to despair”

• Reliability & Friendliness

*Requires clinical depth and breadth of knowledge

*

Psychodynamics 101

• Patients can be vexing.• Diagnostic impasses provoke narcissistic angst.• Frustrated clinicians do not relate well with

patients.• The more tools and capabilities one has, the

greater the freedom, the options, and the ability to positively impact the patient.

• The greater the success, the better the patient feels, the doctor feels, and the doctor-patient relationship feels.

• The converse, worrisomely, also exists.

My experience with “narcissistic angst” – the story of Billy

• 8/1998 – 4 yo Eastern European adopted child – “ADD & behavioral problems, destructive.”– First 3 years of life in orphanage

• Fam Psych Hx:– Dad – “substance induced paranoid psychosis”– Mother – “recurrent schizophrenic

decompensations”

ADHD Diagnosis DSM-IV (TR)

–SIX Symptoms present before age 7 years

–Impairment from symptoms present in 2 or more settings

–Significant social, academic, or occupational impairment

–Exclude other mental disorders

DSM-V–Symptoms rewritten slightly

• FIVE only required for adults

Billy’s symptoms

• “Mercurial” – easy to get along with (except for hyperactivity) then one week at a time will be glowering, sullen, terrible mood, knock brothers over, throw food from table, etc.

• MSE – very hyper. Not able to focus on Nintendo (!) Found standing on top of a box in my video room, supervised by his Dad. DSM-IV: 5/6

• Previous trial of Rx: Adderall 5 mg up to 10 mg. Made him much worse

• ….started on Ritalin and Clonidine

Billy, cont.

• Some improvement• 3/1999 – increasingly vile temper. Sad, dysphoric.

“Back to square one.”– Zoloft added.– Ritalin only lasting 1 ½ hours

• 5/1999 - 4 ½ yoa. Rehab Center testing:– Auditory comprehension = 2 y 11 mo’s– Total language = 2 y 11 mo’s

• 6/1999 – Flaxseed oil, L-tyrosine, Pediactive tabs added. In constant trouble Dad getting depressed.

Billy, cont – 1999 - 2000

• Ritalin and Adderall not working• Temper to the point of clawing at his face.

Sniffing. Now urinating in bed.• 12/1999 – started on Risperdal – 1mg in a.m. and

½ mg later in day• 2/2000 – Psych testing – IQ 78

– ADHD– Borderline intelligence– Processing problems– “r/o childhood psychosis”

Billy, cont.

• 3/2000 – Depakote added to Risperdal for temper and “bipolar” feel. Now doing even worse. Staggering some. – DSM IV 6/7– Risperdal, Tenex, Zoloft, Depakote, Ritalin SR (@ 6

yoa!)

• Summer – Concerta tried. Seemed to respond, then “downhill trend before school started.”

• 10/2000 – “staring spells.” Cleared by neurologist. Negative EEG.

• Mayo suggested; insurance wouldn’t pay.

Billy, late 2000• Fall 2000:

– Bit and stabbed his teacher with a pencil, kicked chair, wall, and desk, spat on floor and teacher. Obsessively lining up his cars in his room, tongue thrusting and smacking (? Tardive dyskinesia?)

• On Risperdal, Depakote, and Concerta.• 8/2001 – 2002 some better but still

unpredictable. Meltdowns. Depakote increased. Zyprexa added.

• 8/2002 – throwing things against windows. Depakote not working. Mood cycling.

May 2002: 9th Annual IFM Conference

Billy, 2003

• Ongoing unpredictability until Geodon started. – Less hyper– Dry in a.m.– Clearer speech and better eye contact.

• July 2003 – IgG food allergy testing ordered

Billy – IgG Food SensitvitiesJuly 2003

• 21 + IgG reactions.. Of these…..– Cheese (3+)– Cow’s milk (3+)– Goat’s milk (2+)– Brewer’s yeast (3+)– Millet (+1)– Lettuce (!) (+1)

Reviewed labs with internet savvy Mom (who did NOTHING).

Billy, 2003 - 2004

• Variable. Food sensitivity diet not really followed.• 9/2003 “absolutely cannot sit still. Moods are

flipping. Gets angry and aggressive really fast.” • 12/2003 – no better

– On Depakote, Geodon, Concerta, Clonidine– 1/2004 – VPA level 122 ug/ml; {50 – 100}

• 3/2004 - “An incredibly nice kid when he’s doing what he wants to do; an asshole when it comes to relating.” (per Dad)

June 7, 2004 – 6 years of tx; ONE YEAR AFTER IgG Testing!

• “Literally bouncing off the walls in the a.m.”• Almost knocked brother off second floor balcony• Could not tolerate < 2 g VPA• Threw stool over banister and tried to hit Mom on

way up stairs. (Missed) • Told Mom: “You’re going to die, I’m going to

make sure you’re going to die.” • Things that make him angry: not putting peanut

butter sandwich on plate “correctly.” • Waking up screaming. Making non-human,

guttural sounds.• Parents pursuing IP treatment

Radical interventions/ workup

• June 2004 – Lithium added– Made him briefly toxic but symptoms improved.– Worked on getting him inpatient tx.

• Fatty acid panel ordered.

• Told Mom to GET SERIOUS about food allergies/sensitivities

Clinical manifestations of EFAD

• Dermatitis• Increased appetite and

caloric intake in infants (adults?!)

• Failure of wound healing• Irritability• Alopecia, dry hair, dandruff• Brittle nails• Increased susceptibility

of infections

• Thirst, polydipsia, polyuria

• Liver fatty infiltration• Increased capillary

fragility• RBC fragility• Increased

Cholesterol/HDL ratio

Essential Fatty Acid findings

Value Reference range

EPA 3 (L) 20 - 80

DHA 32 (L) 70 - 150

FEB 2005

Billy – May 3, 2005• Stable. Has stopped sneaking food.• IgG restrictions: wheat, gluten*, cow’s milk, processed

sugar. (Able to tolerate unprocessed cane sugar.) All forms of chocolate and caffeine.

• Drinks: homemade lemonade, soy or rice milk• Doing a music program at school. “Learning songs he

never could before.”• MEDS: Levocarn; 72 mg Concerta, “DHA heavy” fish oil;

20 mg Geodon (1/2 the previous)– Eliminated: Lithium, Risperdal, and Depakote

• Prognosis: excellent. Still with cognitive challenges, but making progress at school and beginning to catch up. Behavior is stable. No more mood swings or rages.

* Note – not originally seen on testing.

Billy – June 23, 2009• Stable. Teenager. “Doing well except when his will is

crossed.”• IgG restrictions: wheat, gluten, cow’s milk, processed

sugar. (Able to tolerate unprocessed cane sugar.) All forms of chocolate and caffeine.

• More verbal: of CWI therapy pet, he comments, “This dog doesn’t growl; he likes people.”

• MEDS:– “DHA heavy” fish oil twice daily– MVI in a.m– Vyvanse 70 mg, booster MPH in the afternoon; Risperdal 0.5 mg

twice daily, VPA 500 mg ER twice daily .

• ADHD symptoms: – zero – inattentive symptoms – ONE – hyperactive/impulsive symptom

Status: August 17 2011

• “He’s doing great.” • Failed attempts to wean off of IgG food allergies.

– Apples have been added occasionally

– Still can’t do dairy, gluten, citrus, or bananas.

• H.S. sophomore– one year behind (in special ed.) classroom.

• Getting along well with siblings; has not progressed past 1st grade academically, but visual spatial talents excellent.

• Landscaped the entire back yard. Moved 8 tons of rock

Chronology of events:Date Outcome Time to the new

data point from intervention date

8/19/1998 intake

1998-2002 Misc. rx. 4 years

July 2003 IgG food allergy testing – with no compliance. Ongoing Rx.

5 years

June 2004 Ordered Mom to GET SERIOUS ABOUT IgG FOOD ALLERGIES.Ongoing Rx

6 years

August 2004 Patient begins to improve 2 MONTHS

Feb 2005 Distinctly improved 8 months

August 2011 1 year behind grade in special ed ongoing

Losing your child to autism interventions, or…..

Just exactly how fast can you repair a child from the ground up?

“Joey” – the medical and legal train wreck – from e-mail May 31, 2012

Dear Dr. Cady:A week ago Tuesday the Department of Child Services (DCS) removed my son from our home. It was reported that I administered what was deemed “holistic” care to my child. Under the direction of Dr. XXX XXXX, MD my son receives medications, supplements, IV treatments, and mild hyperbaric oxygen. I happen to have my master’s in nursing. In my background I have a year’s work experience in administering IV nutrients and chelation at 2 specialty clinics

Joey - history• Growth slowed at 8 – 9 months• Abdominal pain and colicky as infant.• “The ideal child until 15 months of age.” • May 2010 – exposed to toxins from a bug bomb at 14 – 15

months. Unable to walk the next day. • “He went from a perfectly well-behaved child to not

listening so well. Fussy. Up four times per night.” • July 2010 – dx with autism spectrum. Dairy removed from

diet due to elevate casomorphin. Improved. • April 2011 – nutrient deficiencies on testing: B2, B5, B12,

choline, D3, Zinc and Vitamin C. Rx’ed

Further developments

• May 2011 – URI exposure at friends’ house• “He regressed tremendously, lost all words except

‘ma’ and began stimming behaviors, flapping his arms, blinking his eyes and screaming.”– When his mother turned on the blender, he would

scream for no reason. – Ran into stationary objects– Ceased being cuddly as in the past. – Stopped running to Dad when he came home. – Stopped responding to his name.

Seen by excellent pediatrician – June 6, 2011

• Diagnoses:– Autism Spectrum Disorder (299.00)– Urinary Tract Infection (599.0) – Food sensitivity ( 693.1) – based on the IgG test done in January of

2011– Leaky gut syndrome – which was apparently inferred due to food

allergy – Dysbiosis

• Klebsiella (in stool) • Proteus (in stool)

– Hypothyroidism (with TSH of 15) (!!!)

• Tx’ed with Armour thyroid and multiple supplements (15 ?!) with improvement.

Care transferred to “autism specialist” – August 2011

- Vitamin B 2 - 50 mg daily- Vitamin B12 – Methyl B12 1000

MICROgrams SQ daily - calcium pantothenate 250 – 500

mg daily - choline bitartrate – 300 mg

daily - Vitamin D3 – 2,000 IU per day - zinc glycinate 15 mg daily - copper glycinate – 1.5 mg daily - Vitamin D – 500 mg daily

• MD treatments– IV Secretin– IV glutathione +

NAC– Pre-chelation Zn

and MgSO4– Calcium EDTA –

up to 250 mg in NaCL SIVP x 8 min

“Home treatments” prescribed by “autism specialist”

• IV home treatments: – 5 mg ZnSO4 + 200 mg MgSO4 in 20 cc saline SIVP

• Hyperbaric treatments• Phosphatidyl choline diluted in 50/50 blood mixture,

with slow withdrawal of blood, then mix in syringe, then slowly re-inject – weekly.

• IV UV irradiation treatments• IV secretin

Anonymous complaint filed. DCS worker asks:“Are you giving him chelation treatments??”Anonymous complaint filed. DCS worker asks:“Are you giving him chelation treatments??”

The Comedy of Errors• May 22nd 2012 – removed from home

• GM told to “feed him a normal kid diet.”

• Armour thyroid ordered stopped (as well as all supplements)

• Seen by (Ph.D.) neuropsychologist that “didn’t think he had autism, and that with genetic testing we would be able to treat the root cause.”

• 8/29/2012 - TSH now at 22.10 (H)!!!– (low normal Free T4 and Total T3)

State ordered pediatrician (paraphrased):

“He couldn’t possibly have hypothyroidism because he doesn’t have any thyroid antibodies. This is all probably artifactual anyway because of the cessation of the unnecessary Armour thyroid.”

Since forced removal from home (5/2012 – 8/2012):

• May – would “talk to anybody.”• Regular diet ordered. “Bruises easily.” “Bloated abdomen”• Intermittent constipation• “Foul-smelling stools that would empty the house.” • July – began hiding from strangers and making faces.

“Would stare right through people.”• July 2012 – tantrums escalating in frequency and duration

– now lasting 1 – 1 ½ hours• Throwing toys• Speech had declined• Sleep deteriorated – now up 4 – 5 times per night• MGM: “He is eating fairly large and ravenous amounts.”

Seen for intake in my office – 9/5/2012• Alert. Serious. Intent on toys.

Played with them loudly. Not speaking in complete sentences. Phonated repetitively.

• Huddled down and pulled his lunch box in front of him when I asked him a question.

• Obsessive play with toys. “Push push push.”

Extensive laboratory testing ordered. Armour restarted.

Immediate interventions

• Armour thyroid – ¼ up to ¾ grain titration.• “Starter Pack” of basic supplementation

– Calcium, fish oil, high dose B-complex, minerals– Calcium/magnesium chewables.– Cod liver oil (flavored)

• Supplement with glutathione precursor• DIET: yeast, dairy, and gluten free.• NO CHELATION• NO HYPERBARICS

September 19, 2012September 19, 2012

Organic Acid Testing 9/26/2012

• c/w adrenal stress (low thyroid!!)

• Low 5HIAA = low serotonin – why?

• Also, Quinolinic/5HIAA ratio very high

Milk allergies??

4.73X!4.73X!

Hair analysis 9/20/2012 – toxic elements

Hair analysis 9/20/2012 – essential elements

New interventions (Oct. 2012):

• Tri-enza enzymes with DPP-V

• Increase supplements

• Specific addition of B6 50 mg

• Lithium ionic liquid (1mg)

• Nystatin for yeast

• Flagyl – 10 day course for HPHPA elevation

• Start high potency probiotic after that is done.

December 5, 2012 follow-up• RX:

– Armour thyroid 1 ½ grains; Nystatin; high dose MVI with B-complex; GSH precursors, Cod liver oil, B6, Vit C, probiotics, 1 mg ionic Lithium.

– On food antigen diet.

• Family now able to go to church and sit in pew. Went to MGM’s 95th birthday party.

• Mental Status Examination:– Alert, pleasant, happy, engaging.

Talking more. Gait improved. Speech much more intelligible. Played happily and cooperatively with Dad.

Joey – 1/21/2013• Still with foul stools• Mental Status Examination:

– Alert, pleasant, outgoing. Happy play. “There you go, car man!”

– “I ate all of my chicken.”– Normal gait.

• RX:– Continue with current– Add Uva Ursi.– Try stopping Mg for diarrhea.

11/21/12 29.6 lbs 36”

12/28/12 31.2 lbs 36 & 9/16th”

1/21/2013 33.2 lbs 36 & 15/16th”

1” in 2 mo’s

Disposition

• March 1, DCS involvement ended.

• April 5th – seen for follow-up. Speech improved. – Now on Lactobacillus duo for yeast. – Added Methyl B-12 SQ.

• May 17, 2013 – moved to new location. Now being seen by another specialist. Doing well.

How do you get this done in 3 months?

12/5/20129/5/2012

Images removed from syllabus for patient confidentiality. Patient’s parents have given permission for his images to be shared during the live presentation.

What you can do with an integrated approach in 15 months:

RX: dairy free diet (+IgG test); D3 5000 IU/d; Armour thyroid, Testosterone cypionate 100 mg IM q wk, MVI, Zinc, DHEA 50 mg SR, CoQ10 400mg

(photo shot 15 months after tx)

(permission granted to use photos & data)

Images removed from syllabus for patient confidentiality. Patient has given permission for his images to be shared during the live presentation.

Integrating functional medicine techniques

• Don’t blame the child, the parents, or the adult patient.• If you do not KNOW it’s not a biological, physical problem,

then you simply don’t know. PERIOD.• It’s most likely not a “Risperdal deficiency.” • It’s not an “Axis II” issue unless you have DEFINITIVELY

RULED OUT a biological problem.• Test test test test test. You can’t tell by “looking.”

– FUNCTIONAL MEDICINE TESTING in difficult cases.

• Recognize the importance of DIET.• Appropriate – not excessive – use of supplements and

interventions.– Be able to explain each one. (“The Peter Lynch rule.”)

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

Hair analysis (instead of Organic Acids) done due to staff error!

• Later learned of clothes washing and bathing practices, and derioration of child from early development to present

Radically improved after laundry adjustments!Radically improved after laundry adjustments!

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

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.

• “Favorite food is pizza.”• 12/6/2010 – not totally coherent on MSE. c/o “head hurting.”

Seems generally tired and ill-appearing.– PE – grossly neurologically intact. (Examined).

• OAT test and IgG Food Allergy panel ordered.

“His favorite food is pizza.” – Mom(reviewed December 7, 2010 when these labs were

ordered)

“His favorite food is pizza.” – Mom(reviewed December 7, 2010 when these labs were

ordered)

Organic acid testing – 12/23/2010

Pertains to energy production, Kreb cycle, B vitamins, CoQ10, Mg

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.” – “We need to tell Dr. Cady that that Kroger store in ____

has a lot of gluten free stuff he needs to know about.”

• Liquid fish oil added.

School work 6 weeks later…School work 6 weeks later…

School continuing to insist he is “autistic.”NOTE: doesn’t spin, doesn’t flap, doesn’t engage in stereotypical behaviors. Just had a history of “fits.”

School continuing to insist he is “autistic.”NOTE: doesn’t spin, doesn’t flap, doesn’t engage in stereotypical behaviors. Just had a history of “fits.”

Beginning of resolution….• 4/1/2011 – 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.

IgG results – 3/29/2012

- Started on Nystatin, compounded, liquid – up to 50,000 IU three times daily. Also Probiotic. - ELIMINATE MILK & WHEAT

Progress!

Repeat IgG testing 06/28/2012

Original IgG 3 7 2012

Organic acid test – 6 26 2012

• Arabinose c/w candida (started on NYSTATIN)• 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.

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.

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”

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.

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 PTSD

4. POSSIBLE ADHD

5. LABS ordered

6. RX: – started on 3 mg of Invega, then 6, then 9 as tolerated.– Referred for therapy once bipolar settled.

Rating Scale review – 7/18/2012Results scoring

DSM-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 = max

Jasper-Goldberg RS 94 0 – 120 = range; 70 is cut-off for likely dx of Adult ADHD

Amen Rating Scales 9 symptoms on Inattentive (6 symptoms required for diagnosis)

9 symptoms on overfocused

(5 sxs required for diagnosis)

6 symptoms temporal lobe subtype

6 symptoms required for diagnosis

7 symptoms “limbic” (5 symptoms required for)

10 symptoms “ring of fire” subtype

(5 symptoms required)

Fatigue Severity Scale 56 36 is cut off (63 = max)

Epworth Sleepiness Scale

22 10 is cut off (24 = max)

Follow-up

• 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

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)

BADNESS

GOODNESS

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

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…”

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.

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. (changed to Latuda in

future)– Start Vyvanse at 10 mg, going up by 10 mg every day or

so to 50 mg. (Aliquot technique - Goldilocks) – Increase Armour to one grain; cont DHEA 25 mg

Status – 8/5/2013

• “I definitely know how much healthier I am this year than last year.”

• RX:– Latuda – 80 mg (rash on

Lamictal)– Topirimate (munchies)

– Armour – 1 grain– Viibryd 40 mg /d (OCD)

– PNV with DHA + Fe

– Vyvanse – 50 mg

– L-tyrosine 1000 mg q. afternoon

Image removed from syllabus for patient confidentiality. Patient has given permission for her images to be shared during the live presentation.

Yes – psych patients CAN have medical issues8/7/2012 8/1/2013 Ref range

GGT 135 (H) 22 {7-50}

RBC 2.5 (L!!) 4.57 {4.5 – 10.5}

Hgb 11.4 (L) 14.3 {11.6-14.9}

Hct 33.3% (L) 41.2% {38-48}

MCH 35.2 (H) 31.3 {27-34}

RDW-CV% 14.6% (H) 13.1 {11.5 – 14.5}

Ferritin 46.7 51.1 {10 – 291}

Serum iron 68 68 {50 – 170}

TIBC 368 296 {250-450}

% Fe sat. 18% (L) 23% {20 – 38%}

“I used to drink like the craziest bipolar person you saw in your life.” “I used to drink like the craziest bipolar person you saw in your life.”

Key take-aways from this case

• Don’t let a substance abuse disorder give you a constricted field of logic. – DO NOT NEGLECT THE MEDICAL!!!

• 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.

How I got a patient’s wife pregnant and achieved fame in my time…

A “straight psych” workup?• 26 yo MWM ref by therapist –

5/14/2012.• Presenting issues:

– “obsessive unrealistic uncontrollable thoughts”– “anxiety and constant worry”– “I have strange thoughts that aren’t my thoughts” – “I can’t get rid of some disturbing thoughts.” – “have a low self-esteem & sense of

inadequacy” – “my whole life.”

A “straight psych” workup?• HPI: 2 months ago, acute onset [ego-

dystonic] of images of his wife with her throat cut.

• No previous formal psych history

• Med History: “dx with infertility and inadequate sperm count.” – “not feeling like having sex with wife.”

Eject button?

Labs 5/22/2012TFT’s

TSH 1.4 {0.3 – 5.6}Free T4 0.9 {0.6 – 1.1}|T3 Uptake 37% {24 – 39 – this is NOTE THE LAB I ORDERED.}Reverse T3 31.9 {13.5 – 34.2} 

TESTOSTERONE LEVELS:Total testosterone 227 (L) {348 – 1197; it probably should be in the 900 – 1000 range}Free Testosterone 6.6 (L) 9.3 – 26.5}

LH 5.3 {1.7 – 8.6}

DHEA-Sulfate 301.3 {160-449}

Rx:

• Continue Vilazodone titration for psych symptoms.

• Armour thyroid – ¼ grain x 7d, then ½ grain

• CLOMIPHENE CITRATE – 50 mg tabs – ½ daily x 3 – 5, then one daily

• HCG [human chorionic gonadotropin] injections = 1500 IU twice weekly SQ

• DHEA – 25 mg timed release daily

• Repeat labs ordered.

Labs & sperm count compared:• Previous:

– 400,000 {50 – 150 MILLION}– 35% motility– Low amount ejaculate

• New results - 6/21/2012

• Testosterone 956!! {348-1197}– 125 million (!!!!!) {50 – 150 MILLION}– 85% motility– 4 cc ejaculate

• Patient & wife told to go PARTY DOWN!!• Patient & wife told to go PARTY DOWN!!

E-mail Oct. 19, 2012 –Subject: “Our first baby pic”(nine weeks gestation)

June 11, 2013 – used with permission

Teachable points for this case• It’s not about the “age management” ideas.• It’s about LISTENING to the patient.• OPTIMIZE the biological platform• Refer or consult if you don’t know, but don’t

“wimp out” and push the “delete” or “eject” button on patient concerns. – Don’t say, “it’s not my department; I don’t know

about that.”

• If the patient expresses it, it’s a problem. • The body affects the mind and the thoughts.

How are you feeling?

The Borderless World – Kenichi Ohmae© 1990Revision © 1999

NY Times 8/4/2013

Physician and HCP ratings are coming next!

Physician and HCP ratings are coming next!

“Today, almost 50% of doctors report symptoms of burnout – emotional exhaustion, low sense of accomplishment, detachment.”

“Today, almost 50% of doctors report symptoms of burnout – emotional exhaustion, low sense of accomplishment, detachment.”

SUCCESS: Apple Store, Michigan Avenue, September 20, 2013 – 8:20 PM

Things to consider / action items:

• You must adapt; medicine is changing.– Internet and wide information distribution– Health care expenditures out of control– New paradigms of nutrient insufficiency and

environmental toxins– There are no new “magic bullets.”

• You don’t have to know it all and do it all... But you must be willing to ACKNOWLEDGE and REFER.

Things to consider / action items:

• Do not consider outside diagnoses as indisputable. EVERYTHING is “up for grabs” until proven.

• Integration of functional medicine is like learning to walk – “You do it UNTIL.”

• Humble your ego, admit your ignorance, and ask questions.

• Remain intellectually open and playful.

Start sipping your drinks at PUBMed.gov

Apple Store – Chicago, Michigan Avenue © 2008 Louis B. Cady, MD.

“It’s not the customer’s job to

know what he wants.” - Steve Jobs

“The mind, once stretched by a new idea, never returns to its original dimensions.”

- Ralph Waldo Emerson

It has become necessary to develop medicine as a cooperative science; the clinician, the specialist, and the laboratory workers uniting for the good of the patient, each assisting in elucidation of the problem at hand, and each dependent upon the other for support. Truth is a constant variable.” – William Mayo, MD. “Dr. Will” - 1910

Historical display case. In “subway” – Mayo Clinic. © Louis B. Cady, M.D.

“For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room openinginto another hallway, again lined with doors. Medicine is always wonderful and never will be finished.”- Charles H. Mayo, M.D.

Contact information:

Louis B. Cady, M.D.

www.cadywellness.comwww.facebook.com/cadywellness

www.tms-relief.com

Office: 812-429-0772E-mail: lcady@cadywellness.com

4727 Rosebud Lane – Suite FInterstate Office Park

Newburgh, IN 47630 (USA)

@LouisCadyMD@TMS4depression

Once more…. Where to “get the slides” -

Syllabus

www.slideshare.net/lcadymd

Cady Wellness Institute app.