Case Study 6


Age 35.  

This is a real patient history. Their identification details have been removed to maintain the patient’s privacy.

Initial Presentation

  • Presented with already made diagnosis of pyloruria, on high dose of zinc and SAM–e for years but very stressed, depressed and anxious
  • Worried about her anxiety, depression and tiredness
  • Runs her own business
  • Mother of two daughters, both have got behavioural problems
  • Lives with her husband (separated from previous husband as he was very abusive)
  • Childhood was not very troublesome except for father’s depression and alcoholism and mentally ill. Abusive brother who eventually became a psychotic.
  • Mum suffers from anxiety throughout her life.
  • Patient reported feeling unwell, drained, depressed, and poor gut health. (Her mum was also told that she has got polyuria but found to have methylation issues.)
  • Patient has been on a number of supplements when she presented to me.
  • Tentative diagnoses of ADHD, Depression, Anxiety, Dyslexia, Pyloruria
  • Allergies – None
  • Never smoked
  • Alcohol only once in 2 – 3 months
  • Family History
    • Mother, Father, Brother, Maternal Uncle – Depression and Anxiety
    • Brother – Psychosis
  • Physical Exam
    • Looks Anxious. And bit agitated, pressurised speech
    • BMI – 36.55
    • Otherwise normal looking
  • More about Life
    • Mum and dad separated
    • Step-dad died and the mum and patient tried to resuscitate him which was very traumatic.
    • Brother was very physically abusive to the patient (He suffered from ADHD, Asperger’s Autism, Oppositional Defiance Disorder and Dyslexia)
  • Assessment
    • Fatigue Questionnaire
      • Total Score – 70
      • Responded Positive to 18/20 main fatigue questions
    • Yeast symptom Questionnaire
      • Score – 268
    • Dysbiosis Questionnaire
      • Score – 66
    • Mental Health Screening Questionnaire
      • Features of moderate to severe depression
      • Symptoms of severe anxiety
      • Beck’s Depression Scale Score – 31
      • Beck’s Anxiety Scale Score – 29
      • Brain Health Questionnaire
        • High scores for many of the brain areas
      • Severe serotonin deficiency symptoms
      • Severe dopamine deficiency symptoms
    • Hormone Assessment Questionnaire
      • Oestrogen Dominant Symptoms
    • Toxin Score – 148
    • Gene Screening Questionnaire
      • MTHFR, Slow COMT, Fast COMT, Slow MAOA, Fast MAOA
        • Positive Symptoms for above SNPs (these are for screening purposes only and may not  represent actual SNP defects)

Review 03/09/19

  • Yeast symptom Score – 225
  • Dysbiosis Score – 65
  • Toxin Score – 125
  • Fatigue Score – 121

Review – 20/01/20

  • Patient feels much better
  • Depression and anxiety symptoms are very much reduced
  • More energetic
  • Gut symptoms are hugely improved
  • Above protocol will be continued until next review
  • Lost to follow up due to COVID-19