I have a two-part question on a new patient. I’m wondering your initial thoughts and where you would be thinking on this case study besides initial workup with labs. A 25-year-old patient, often tired. Pushes through, but it’s a struggle. She was on Vyvanse for a year at the age of 20 and is off it completely. She has taken Sudafed to work through a cold and has noticed helpful cognitive benefits. She doesn’t want to take either of these amphetamines for obvious reasons, but she has tried different amino acids before, and they give her extreme headaches. Sleep is good, and she follows a Paleo diet and lifestyle, but energy and cognitive function are not optimal. She also mentioned it’s hard for her to sleep if she does not eat potatoes with dinner. Where would you start, and how would you start thinking in this case?

Chris Kresser:  For sure, I would do a comprehensive workup, and an HPA axis assessment would be a big part of that, including the DUTCH testing, but also the questionnaires and other assessment tools we’ve talked about. From her symptoms, I would predict that she has cortisol dysregulation, probably high cortisol at night, possibly low cortisol either overall or maybe free cortisol … Oh, yeah, you said her sleep is good, but it could be nonrestorative, so you still want to check her cortisol levels at night because her energy and cognitive function are not optimal. The kind of patient presentation, the patient type that needs a higher carbohydrate load, especially at night to sleep well, often does have HPA axis dysfunction, so I would certainly look at that. You also want to look at her blood chemistry, which you’ll be learning to do shortly to look for things like B12 deficiency and iron deficiency that can cause fatigue and also deficiencies of other nutrients and blood sugar dysregulation.

It’s almost like the more nonspecific the symptom is, the more you need the comprehensive workup. That can be challenging in some cases because a patient who has just a general nonspecific symptom might be reluctant to do that, but it’s even more important because you don’t have more signposts pointing … When you have a very specific set of symptoms, it’s easier to guess what the problem might be, based on the symptoms, but when you have a really nonspecific symptom, it’s more challenging.