The challenge
For six years, Miguel struggled with a pattern no one believed.
The 18-year-old experienced severe, cyclical symptoms: brain fog, fatigue, and mood disturbance lasting 2–4 days at a time. Between episodes, he functioned brilliantly. “School was fun. He can focus. He reads for pleasure.” Then it would hit again, and he’d feel “like a different person.”
Multiple providers suggested it was “all in his head.” His family was “tired of hearing about it.”
His screening scores seemed to confirm the dismissal: PHQ-9 of 4 (minimal depression), GAD-7 of 2 (minimal anxiety). An easy case to reassure and move on.
What standard care would have done
Standard care would have validated his concerns, maybe ordered basic labs, and moved on. The supplements he was taking daily would never have been scrutinized. His family’s dismissal would have reinforced his sense that he was imagining things.
What Assess surfaced
Comprehensive assessment revealed a picture that required connecting dots across multiple domains:
- The supplement paradox. Miguel was taking daily ashwagandha (500mg) to treat his brain fog. Literature review revealed ashwagandha’s documented side effects include brain fog, fatigue, and depression. The supplement he was taking to fix his symptoms may have been causing them.
- Episodic symptoms invisible to screening. His symptoms only appeared cyclically, making them invisible to standard tools that query “the past 2 weeks.” PHQ-9 and GAD-7 don’t capture state-dependent functioning.
- Family dismissal as barrier to care. Miguel endorsed “neglect” on our safety screener. Exploration clarified: his mother was “tired of hearing about it” and both parents thought it was psychosomatic. This dismissal created secondary distress and delayed care-seeking.
- Historical suicidal ideation surfaced through trust. During the assessment process, Miguel disclosed passive suicidal ideation from approximately 3 years prior that he’d never shared with other providers.
What changed
Diagnosis: Adjustment Disorder with Mixed Anxiety and Depression, with possible supplement-induced cognitive effects and circadian rhythm disruption.
- Comprehensive supplement evaluation with specific ashwagandha warning
- Sleep study for detailed observation
- CBT with focus on the cyclical symptom pattern
- Crisis resources provided and saved in phone
Miguel engaged throughout all four assessment sessions—finally feeling heard after years of dismissal.
”Usually I feel good. I feel pretty sharp and I do things a lot faster, a lot easier. But on those days... I just feel like a different person.
Miguel, 18PHQ-9: 4 | GAD-7: 2
Impact by the numbers
Metric
Our Assessment
Industry Benchmark
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These findings came from real assessments at Texas Center for Lifestyle Medicine. We have detailed documentation on 50+ patient evaluations, with more being added from ongoing clinical work.
