This is the third of four CME lectures delivered by Dr. Cady at the 4rth Annual Integrated Medicine For Mental Health Conference in Chicago, IL at McCormick Place, on September 22, 2013. He draws parallels between the story of Moliere's famous drunken wood-cutter, Sgnarelle, and his own inauspicious beginnings in the field of functional medicine until a remarkable encounter with a patient permanently changed his life and convinced him of the necessity of IgG food allergy testing. As this presentation is developed, more intriguing patient vignettes are presented, always with the dual foci of (a) what is TRULY WRONG with the patient, and (b) is the physician doing EVERYTHING HE/SHE CAN to restore the patient to health and wellness. Never one to dodge controversy, Dr. Cady talks candidly about what he has done, the grounding in the peer-reviewed medical literature and how a combination of thoughtful testing facilitates precise diagnosis and efficient treatment.

1. 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 Wellness InstituteLouis B. Cady, MD – CEO & Founder – Cady Wellness Institute

2. 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

3. Le medicin malgre lui –
Moliere, 1666
Microsynopsis: Sgnarelle – an alcoholic woodcutter forced into
posing as a doctor who becomes rich and respected.

4. “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”

5. 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].

6. 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
*

7. 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.

8. 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”

9. 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

10. 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

11. 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.

12. 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”

13. 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.

14. 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.

15. May 2002: 9th
Annual IFM Conference

18. 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

19. Billy – IgG Food Sensitvities
July 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).

20. 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)

21. 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

22. 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

23. 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

24. Essential Fatty Acid findings
Value Reference range
EPA 3 (L) 20 - 80
DHA 32 (L) 70 - 150

26. FEB
2005

27. 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.

28. 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

29. 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

30. 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

31. Losing your child to autism
interventions, or…..
Just exactly how
fast can you repair
a child from the
ground up?

32. “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

33. 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

34. 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.

35. 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.

36. 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

37. “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??”

38. 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)

40. 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.”

41. 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.”

42. 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.

43. 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

45. September 19, 2012

46. Organic Acid Testing 9/26/2012

47. • c/w adrenal stress (low thyroid!!)
• Low 5HIAA = low serotonin – why?
• Also, Quinolinic/5HIAA ratio very high

49. Milk allergies??
4.73X!4.73X!

50. Hair analysis 9/20/2012 – toxic elements

51. Hair analysis 9/20/2012 – essential
elements

52. 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.

53. 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.

54. 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

55. 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.

56. 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.

57. 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.

58. 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.”)

59. 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

60. 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!

61. 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

62. 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.

63. “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)

64. Organic acid testing – 12/23/2010
Pertains to energy production, Kreb cycle, B vitamins, CoQ10, Mg

65. 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.

66. 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.”

67. 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.

68. IgG results – 3/29/2012

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

70. Progress!
Repeat IgG testing 06/28/2012
Original IgG 3 7 2012

71. 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.

72. 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.

73. 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”

74. 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.

75. DX/RX – 7/18/2012
1. 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.

76. Rating Scale review – 7/18/2012
Results 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)

77. 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

78. 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)

81. BADNESS
GOODNESS

82. 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

83. 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…”

84. 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.

85. 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

86. 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.

87. Yes – psych patients CAN have medical issues
8/7/2012 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.”

88. 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.

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

90. 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.”

91. 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?

92. Labs 5/22/2012
TFT’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}

93. 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.

94. 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!!

95. E-mail Oct. 19, 2012 –
Subject: “Our first baby pic”
(nine weeks gestation)
June 11, 2013 – used with permission

96. 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.

97. How are you feeling?

98. The Borderless World –
Kenichi Ohmae
© 1990
Revision © 1999

99. NY Times 8/4/2013

102. Physician and HCP
ratings are coming
next!
Physician and HCP
ratings are coming
next!

105. “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.”

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

108. 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.

109. 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.

111. Start sipping your drinks at PUBMed.gov

112. Apple Store – Chicago, Michigan Avenue © 2008 Louis B. Cady, MD.
“It’s not the
customer’s job to
know what he wants.”

113. “The mind,
once stretched
by a new idea,
never returns
to its original
dimensions.”
- Ralph Waldo
Emerson

114. 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.

115. “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 opening
into another hallway,
again lined with doors.
Medicine is always
wonderful and never will
be finished.”
- Charles H. Mayo, M.D.

116. Contact information:
Louis B. Cady, M.D.
www.cadywellness.com
www.facebook.com/cadywellness
www.tms-relief.com
Office: 812-429-0772
E-mail: lcady@cadywellness.com
4727 Rosebud Lane – Suite F
Interstate Office Park
Newburgh, IN 47630 (USA)
@LouisCadyMD
@TMS4depression
Once more…. 
Where to “get the slides” -
Syllabus
www.slideshare.net/lcady
md
Cady Wellness Institute
app.