by Jeffrey Dach MD
A case was presented at the Medical University of South Carolina. The patient was a 23 year old female with paranoid psychosis treated unsuccessfully with anti-psychotic medications and shock therapy. The treatments only made her worse. Eventually, further testing revealed the patient had a severe vitamin B12 deficiency, and was finally given Vitamin B12 injections resulting in a dramatic improvement. (1)
A second case involves a 52-year-old female who had a complete remission of psychiatric symptoms without recurrence over four years with vitamin B12 as the only treatment.(2) There are many others. (3-11)
A Common Mistake by Psychiatry
These two cases highlight the common mistake made by my dear colleagues in psychiatry who fail to look for organic causes of mental illness. Vitamin B12 deficency is one of the more common of the organic causes detected by a serum B12 level and urinary methyl malonate. How many neuro-psychiatric patients actually have undiagnosed B12 deficiency ? Your guess is as good as mine. We will probably never know.
Perhaps this blindness to B12 deficiency is a symptom of a larger problem with our psychiatric colleagues who tend to ignore organic causes of mental illness, while mindlessly rushing into treatments with psycho-active drugs, shock therapy and the dreaded frontal lobotomy.
B12 Deficiency and Dementia in the Elderly
As we reach old age, the incidence of dementia with cognitive dysfunction goes up. Similarly, B12 deficiency goes up, a manifestation of malabsorption of the vitamin which worsens as we age. It is important not to miss the diagnosis of B12 deficiency, since this is a reversible cause of dementia in the elderly.
Above Left Image B12 chemical structure. Notice CN (Cyanide molecule) at center, this is cyano-cobalamin. We use the methylcobalamin version, the preferred form of the vitamin. Courtesy Wikimedia Commons.
Hashimotos Thyroid Disease
Another common misdiagnosis in the Psych Ward is the thyroid disorder, specifically Hashimoto’s thyroiditis which can mimic a manic-depressive disorder. See my previous article on this.
Another common misdiagnosis is that of gluten sensitivity and gluten induced neuro-psychiatric disorders which resolve upon going on a gluten free diet. See my previous article on this. A book entitled Grain Brain by David Perlmutter MD, a neurologist in Naples Florida, deals with gluten induced neuro-psychiatric disorders.
Another common misdiagnosis is the MTHFR mutation which is gene responsible for the conversion of folate to its active form methyl-folate. This mutation may affect ability to synthesize neurotransmitters in the brain and is treatable with a vitamin called methyl-folate. Instead, my dear psychiatric colleagues blindly rush into treatment with various dangerous and addictive psychoactive medications such as amphetamines, benzodiazepines, atypical antipsychotics and combinations of SSRI antidepressants in or out of the hospital psych ward. Some may even get shock therapy. You might notice that none of these medications contain methy-folate which is the single item the patient really needs. See my previous article on this.
Post menopausal Estrogen Deficiency Classified as Psychiatric Disorder
Another glaring error bordering on criminality is the tendency of modern psychiatry to classify estrogen deficiency in post-menopausal women as a psychiatric disorder to be treated with psych meds. The latest outrage is the FDA approval of Brisdell, an SSRI antidepressant, for hot flashes of menopause. Hot Flashes, anxiety and panic attacks are estrogen deficiency symptoms, relieved with bioidentical estrogen. SSRI anti-depressants do not contain estrogen, and their use for estrogen deficiency is an abuse and victimization of women who suffer from estrogen deficiency. SSRI drugs should not be used to treat estrogen deficiency symptoms. I discussed this in a previous article.
Low Testosterone as Underlying Cause of Depression
In men, low testosterone has been known to cause depression and treatment with testosterone is very effective. Rather than test testosterone levels and treat this underlying cause, the psychiatry clinic will dispense various antidepressants and psychoactive drugs, none of which contain testosterone and are largely ineffective in this scenario. (links to medical literature on this topic).
Adrenal Insufficiency Mimicking Psychosis and Depression
Low cortisol adrenal insufficiency (also called Addison’s Disease) will commonly present as a neuro-psychiatric disorder, depression, psychosis, etc. and will frequently be misdiagnosied until a complete blood panel is obtained including electrolytes, cortisol and ACTH levels. The patient with adrenal fatigue, adrenal insufficency and low cortisol output may have chronic fatigue, depression, skin pigmentation, muscle weakness, etc. Examination often reveals orthostatic hypotension and unstable pupils. The laboratory panel may show low serum sodium, elevated potassium, low Cortisol, and elevated ACTH (for primary adrenal failure) etc. ACTH stimulation test or 24 hour urine collection for cortisol metabolites provides a definitive diagnosis These patients respond to hydrocortisone treatment with resolution of symptoms.(11-15) See my previous article on low cortisol adrenal fatigue.
HPA Disruption Causing Neuro-Psychiatric Diorders
Disturbance of the HPA hypo-thalamic-pituitary axis is common from many prescription and street drugs which have psycho active properties. Examples are MDMA, Ecstasy-type street drugs, Narcotics, Benzodiazepines, Alcohol , etc. HPA disturbance may continue many years after the causative drug has been discontinued. These patients are commonly given psychiatric drugs which do not address the underlying problem. Rather than treat with psychoactive drugs, these patients should need supportive treatment to allow the endocrine system and HPA to return to normal functioning.
See my previous article on this endocrine system disruption from narcotics.
Also see this article on restoring HPA function in patients presenting with low testosterone induced by street drug use.
One of the failings of modern medicine is the way in which our psychiatric colleagues ignore the underlying organic causes of mental illness. This results in the misdiagnosis and mistreatment of many unfortunate souls leaving behind a trail of human misery.(16-17)
There are many more organic causes of mental disorders as we have barely scratched the surface. All this makes it obvious that Psychiatry needs a “makeover”. The rank and file psychiatric practitioner needs to go back to square one, get a re-education in the underlying organic causes of mental illness, and remake the way they practice. Blindly dispensing psychoactive drugs, shock therapy and other ineffective measures creates the tragedy known as modern psychiatric treatment.
One such psychiatrist who has made this transition is Kelly Brogan. Read her article on Vitamin B12 Deficiency and Brain Health.
Articles with Related Interest:
Jeffrey Dach MD
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This article is part two of a series. For part one, click here.
J Psychiatr Pract. 2009 Sep;15(5):415-22.
Malignant catatonia in a patient with bipolar disorder, B12 deficiency, and neuroleptic malignant syndrome: one cause or three? Lewis AL1, Pelic C, Kahn DA. Medical University of South Carolina, Charleston, USA.
A Case is presented of a 23-year-old woman with progressive onset of paranoid psychosis and catatonia, who was ultimately found to have both vitamin B12 deficiency and a family history of bipolar disorder. The patient was initially diagnosed with schizophrenia and treated with the antipsychotic medication ziprasidone. Her condition rapidly worsened to a state consistent with either neuroleptic malignant syndrome or malignant catatonia. Work-up then revealed vitamin B12 deficiency and a family history of bipolar disorder. Her symptoms improved rapidly but partially with benzodiazepines and electroconvulsive therapy, and completely with addition of valproic acid, vitamin B12 replacement, and re-introduction of antipsychotic medication in the form of olanzapine. The authors discuss the differential diagnosis of catatonia as reflecting a high likelihood of underlying mood disorder; the evaluation and management of malignant catatonia and malignant neuroleptic syndrome; and the role of vitamin B12 deficiency in precipitating psychotic symptoms. The case also illustrates the problems of diagnosing and managing a multifactorial disorder with psychiatric, general medical, and perhaps iatrogenic components.
Acta Psychiatr Scand. 2003 Aug;108(2):156-9.
Catatonia and other psychiatric symptoms with vitamin B12 deficiency.
Berry N1, Sagar R, Tripathi BM.
To study unusual psychiatric manifestation of vitamin B12 deficiency and related issues.
METHOD:A case study of 52-year-old female and review of relevant literature.
RESULTS:Complete remission of psychiatric symptoms without recurrence for the next 4 years with vitamin B12 as the only specific therapy instituted.
CONCLUSION:Importance of B12 estimation and replacement in patients with varied psychiatric manifestations.
Encephale. 2003 Nov-Dec;29(6):560-5.
[Psychiatric manifestations of vitamin B12 deficiency: a case report].
Durand C1, Mary S, Brazo P, Dollfus S. 1Centre Esquirol, Service du Professeur S. Dollfus, CHU de Caen, avenue Côte-de-Nacre, 14033 Caen.
Neurol India. 2004 Mar;52(1):122-3.
Recurrent seizures: an unusual manifestation of vitamin B12 deficiency.
Kumar S. The present report highlights an unusual presentation of vitamin B12 deficiency–recurrent seizures in a 26-year-old man. His symptoms responded to parenteral vitamin B12 therapy. The relevant literature is reviewed.
J Trop Pediatr. 2009 Jun;55(3):205-7. doi: 10.1093/tropej/fmn112. Epub 2008 Dec 18.
Psychotic disorder and extrapyramidal symptoms associated with vitamin B12 and folate deficiency. Dogan M1, Ozdemir O, Sal EA, Dogan SZ, Ozdemir P, Cesur Y, Caksen H. Vitamin B12 and folate deficiency causing neuropsychiatric and thrombotic manifestations, such as peripheral neuropathy, subacute combined degeneration of cord, dementia, ataxia, optic atrophy, catatonia, psychosis, mood disturbances, myocardial infarction and portal vein thrombosis are well known.
This present report highlights an unusual presentation of vitamin B12 deficiency-psychotic disorder, extrapyramidal symptoms in a 12-year-old boy. His symptoms responded to parenteral vitamin B12 therapy. So with this report we emphasized that serum vitamin B12 and folate levels should be measured, especially in those patients who present with other known neuropsychiatric features of vitamin B12 and folate deficiency.
Vitamin B12 Deficiency and Brain Health
Posted by Kelly Brogan MD in Article
It Could Be Old Age, or It Could Be Low B12 By JANE E. BRODY
Published: November 28, 2011
Others at risk of developing a B12 deficiency include heavy drinkers (alcohol diminishes B12 absorption), those who have had stomach surgery for weight loss or ulcers, and people who take aminosalicylic acid (for inflammatory bowel disease or tuberculosis) or the diabetes drug metformin (sold as Glucophage and other brands). Patients who take the anticonvulsants phenytoin, phenobarbital or primidone are also at risk.
Vitamin B12 Deficiency. ROBERT C. OH, CPT, MC, USA, U.S., Army Health Clinic, Darmstadt, Germany DAVID L. BROWN, MAJ, MC, USA, Madigan Army Medical Center, Fort Lewis, Washington
Am Fam Physician. 2003 Mar 1;67(5):979-986.
Vitamin B12 (cobalamin) deficiency is a common cause of macrocytic anemia and has been implicated in a spectrum of neuropsychiatric disorders. The role of B12 deficiency in hyperhomocysteinemia and the promotion of atherosclerosis is only now being explored. Diagnosis of vitamin B12 deficiency is typically based on measurement of serum vitamin B12 levels; however, about 50 percent of patients with subclinical disease have normal B12 levels. A more sensitive method of screening for vitamin B12 deficiency is measurement of serum methylmalonic acid and homocysteine levels, which are increased early in vitamin B12 deficiency. Use of the Schilling test for detection of pernicious anemia has been supplanted for the most part by serologic testing for parietal cell and intrinsic factor antibodies. Contrary to prevailing medical practice, studies show that supplementation with oral vitamin B12 is a safe and effective treatment for the B12 deficiency state. Even when intrinsic factor is not present to aid in the absorption of vitamin B12 (pernicious anemia) or in other diseases that affect the usual absorption sites in the terminal ileum, oral therapy remains effective.
9) full text pdf Vitamin B12 Deficiency_Sally_stabler_NEJM_2013
Stabler, Sally P. “Vitamin B12 deficiency.” New England Journal of Medicine 368.2 (2013): 149-160.
Laboratory Evaluation for Vitamin B12 Deficiency: The Case for Cascade Testing . Clin Med Res. Feb 2013; 11(1): 7–15.Richard L. Berg, MS* and Gene R. Shaw, MD† * Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, Wisconsin, USA
The Neuropsychiatric Aspect of Addison’s Disease. A Case Report Mohamed Abdel-Motleb, MD Innov Clin Neurosci. Oct 2012; 9(10): 34–36.
J Neuropsychiatry Clin Neurosci. 2006 Fall;18(4):450-9.
The neuropsychiatric profile of Addison’s disease: revisiting a forgotten phenomenon. Anglin RE1, Rosebush PI, Mazurek MF.
One hundred fifty years since Thomas Addison’s original description of the disease, it is not commonly appreciated that patients with Addison’s disease may present with psychiatric symptoms. A review of the literature indicates that disturbances in mood, motivation, and behavior are associated with Addison’s disease. Psychosis occurs less frequently, but can be the presenting symptom of a life-threatening adrenal crisis. Potential mechanisms for the neuropsychiatric symptoms of Addison’s disease include electrophysiological, electrolyte and metabolic abnormalities, glucocorticoid deficiency, increased endorphins, and an associated Hashimoto encephalopathy. Physicians must be aware that Addison’s disease may present solely with psychiatric symptoms and maintain a high index of suspicion for this potentially fatal condition.
Seishin Shinkeigaku Zasshi. 2004;106(9):1110-6.
[A case of Addison’s disease presented with depression as a first symptom].
[Article in Japanese] Iwata M1, Hazama GI, Shirayama Y, Ueta T, Yoshioka S, Kawahara R.
This report describes a 52-year-old male patient with idiopathic Addison’s disease presenting depression as a first symptom. His psychomotor inhibition, depressive mood, sleep disturbances, general fatigue, muscular pain, and arthralgia were considered to be due to intense work in a stressful environment. Neither his physician nor his orthopedist found any physical disease. Therefore, he was diagnosed with endogenous depression by a psychiatric clinic, and antidepressants were prescribed. Antidepressants were not sufficient for improving his symptoms, and he was admitted to our hospital. Endocrine blood examination revealed primary adrenocortical insufficiency. Treatment with glucocorticoid induced rapid improvement in both the psychiatric and physical symptoms. It is well known that psychiatric symptoms occur in the progressive stage of Addison’s disease. At present, however, the occurrence of psychiatric symptoms is very rare, mainly because of a decrease in the incidence of this disease or an increase in mild cases. In addition, Addison’s disease presenting with psychiatric features in the early stage has the tendency to be overlooked and misdiagnosed. Thus, we suggest the necessity of blood work for ACTH and cortisol in the field of psychiatry.
Gen Hosp Psychiatry. 2014 Mar 5. pii: S0163-8343(14)00062-0. doi: 10.1016/j.genhosppsych.2014.
Morigaki Y1, Iga JI2, Kameoka N2, Sumitani S2, Ohmori T2.
We report a 59-year-old man with isolated adrenocorticotropin (ACTH) deficiency. The patient presented with sudden onset of delusions and hallucinations at the age of 54, which resolved gradually without treatment. Subsequently, the patient manifested stereotypy, wandering, hypobulia, and autistic symptoms, and was treated with antipsychotics for 1 year without any improvement. He suffered from neuroleptic malignant syndrome-like symptoms at the age of 59. A thorough endocrine assessment revealed isolated ACTH deficiency. After hydrocortisone supplementation, the physical and psychiatric symptoms improved dramatically. Clinicians should consider this rare disease when diagnosing patients with refractory psychiatric symptoms and unique physical symptoms of isolated ACTH deficiency.
Intern Med. 2001 Jun;40(6):510-4.
Three patients with isolated adrenocorticotropin deficiency presenting with neuroleptic malignant syndrome-like symptoms.
Sekijima Y1, Hoshi KI, Kasai H, Okada M, Namiki S, Ohta K, Nakano T, Hirayama J, Ikeda SI.
We report 3 patients with isolated adrenocorticotropin (ACTH) deficiency presenting with neuroleptic malignant syndrome (NMS)-like symptoms. All patients were in their 60’s or 70’s and showed consciousness disturbance, a high-grade fever, extrapyramydal signs, and muscle enzyme elevations, which met the criteria for NMS. Also, they all showed hyponatremia induced by isolated ACTH deficiency. In addition to the standard therapy for NMS, corticosteroid supplement therapy was effective in all patients. There thus appear to be subjects with isolated ACTH deficiency among patients presenting with NMS-like symptoms, and adrenal and pituitary function should be checked in NMS patients with hyponatremia.
HOW TO TELL IF SOMEONE DIAGNOSED WITH A MENTAL ILLNESS, HAS ANOTHER MEDICAL DISORDER (THAT MAY HAVE LED TO A MISDIAGNOSIS) by DR. RON DIAMOND
17) Physical_Illness_Presenting_Psychiatric_Disease Physical Illness Presenting as Psychiatric Disease Richard Hall Arch Gen Psych 1978
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