Initial Presentation

Douglas was a 22 year-old male who came to our office seeking help for long-standing attention-deficit/hyperactivity disorder (ADHD), panic disorder and post-traumatic stress disorder (PTSD). Douglas’ PTSD stemmed from a traumatic incident involving physical and sexual abuse when he was 15. During work and school situations, he often became agitated and had emotional outbursts or panic attacks. Due to the severity of his symptoms, he had recently withdrawn from college and quit a part-time job.

For his symptoms, a previous provider had prescribed 150 mg of sertraline, which Douglas continued to take with minimal benefit. In high school, he had been on Ritalin which felt overly stimulating and disrupted his sleep.

Initial relevant labs

• 25-hydroxy vitamin D: 14.2 Low
• RBC Magnesium: 3.5 mg/dl Low
• Methylmalonic acid (a marker for B12 deficiency when elevated): 342 nmol/L High
• Amino acid (AA) levels on a serum AA panel: Numerous AAs were low
• Urine organic acid testing showed gut microbiome disturbances or potential dysbiosis

Initial Treatment

• Vitamin B12 injections: Methylcobalamin 1000 μg twice per week
• Vitamin D: 10,000 IU per day
• Magnesium glycinate 240 mg twice per day

Explanation

Low vitamin D levels have been associated with PTSD (Terock 2020). The vitamin is known to be important for maintaining proper levels of serotonin in the brain (Sabir 2018). Magnesium is also critical for a healthy stress response, has anti-inflammatory properties and can improve both mood and anxiety levels (Maier 2021, Pickering 2020, Botturi 2021). Vitamin B12 is also necessary for the synthesis of serotonin, norepinephrine and dopamine while helping to reduce the neurotoxic amino acid homocysteine. Elevated homocysteine has been correlated to worse outcomes due to trauma (Tien 2022).

Follow-up Presentation

Over the next few weeks Douglas described modest reductions in the frequency and intensity of his panic attacks. At his one-month follow-up, two treatments were added:

Follow-up Treatment

• An amino acid formula called Amino Replete, 1 scoop twice daily on an empty stomach
• The yeast probiotic Saccharomyces boulardii, 1 cap twice daily
• B12 injections were replaced with a daily B-complex vitamin

Explanation

Amino acids are critical precursors for the production of neurotransmitters. When low, as shown in tryptophan depletion studies, they can negatively influence mental health (Booij 2002). Dysbiosis, or detrimental changes in the gut microbiome, have been shown to correlate with poor mental health (MacKay 2023). Supplementation with probiotics can support the gut-brain axis and improve mood (Zhang 2023). While best studied for treating childhood diarrhea and the side effects from antibiotics (Fu 2022, Guo 2019), Sacchromyeces boolardii can also be helpful in more general cases of dysbiosis.  

Additional Follow-up

After additional improvements over the next few months, the sertraline was tapered and Vyvanse was added to help with residual ADHD symptoms. Upon testing, vitamin D levels had improved and dosing was reduced to 5000 iu per day.

As treatment progressed, Douglas felt stable enough to re-enroll in college and started working again. His care was ongoing. Overall, Douglas was encouraged with his progress to date and felt like he had his life back, especially since restarting work and school.

Case Summary

The traumatic experiences in Douglas’ youth, combined with nutritional deficiencies and gut flora problems, were driving the severity of his symptoms. By removing the biochemical stressors on his system with proper nutritional support and probiotics, his overall symptom picture became more manageable. While still receiving care, his quality of life and ability to function had significantly improved. While cases like this one can be complex, by focusing on the basic foundations of care, other treatments, in this case, Vyvanse, often work better with fewer side effects.