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Blom JD. Hallucinations and Vitamin B12 Deficiency: A Systematic Review. Psychopathology 2024:1-12. [PMID: 39047712 DOI: 10.1159/000540003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 06/17/2024] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Vitamin B12 deficiency is primarily associated with pernicious anaemia, polyneuropathy, and spinal-cord disease, but publications on its association with hallucinations are on the rise. METHODS I carried out a systematic literature search on these hallucinations in PubMed, PsycINFO, and Google Scholar, up until July 1, 2023. RESULTS The search yielded 50 case studies published between 1960 and 2023. The hallucinations described therein are predominantly visual and/or auditory in nature, with 20% being specified as complex, compound, or panoramic. They are often described in the context of vitamin B12-related neuropsychiatric conditions such as dementia, delirium, epilepsy, psychotic disorder, schizoaffective disorder, bipolar disorder, depressive disorder, catatonia, or obsessive-compulsive disorder. In the context of such disorders, they tend to appear first and also often appear to be the first to disappear with cobalamin treatment. Within an average of 2 months, full amelioration was thus obtained in 75% of the cases and partial amelioration in the remaining 25%. Remarkably, a quarter of the cases involved therapy-resistant hallucinations that fully resolved under cobalamin monotherapy, while other neuropsychiatric manifestations of vitamin B12 deficiency disappeared in 60% of the treated cases. Only 32% of the cases involved comorbid pernicious anaemia. This suggests that two separate or diverging pathways exist for perceptual and haematological symptoms of vitamin B12 deficiency. CONCLUSION In the light of the high prevalence rate of vitamin B12 deficiency in the general population, the findings here presented should be interpreted with great caution. Nonetheless, they offer cues for further research and experimental application in clinical practice. This may be especially relevant in light of the recent increase in the popularity of vegetarianism and the recreational use of nitrous oxide (laughing gas), which are both risk factors for vitamin B12 deficiency.
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Affiliation(s)
- Jan Dirk Blom
- Outpatient Clinic for Uncommon Psychiatric Syndromes, Parnassia Psychiatric Institute, The Hague, The Netherlands
- Faculty of Social and Behavioural Sciences, Leiden University, Leiden, The Netherlands
- Department of Psychiatry, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Of the water-soluble vitamins, vitamin B12 (B12) has the lowest daily requirement. It also has several unique properties including a complex pathway for its absorption and assimilation requiring intact gastric and terminal small intestinal function, an enterohepatic pathway, and several dedicated binding proteins and chaperons. The many causes of B12 deficiency include malabsorption and defects in cellular delivery and uptake, as well as limited dietary intake. B12 is required as a cofactor for only two reactions in humans, the cytosolic methionine synthase reaction and the mitochondrial methymalonyl CoA mutase reaction. Disruption of either of these reactions gives rise to B12 deficiency. Although more common with advancing age, because of the higher prevalence of malabsorptive disorders in the elderly, B12 deficiency is widely distributed across all age groups particularly where food insecurity occurs. The consequences and severity of B12 deficiency are variable depending on the degree of deficiency and its duration. Major organ systems affected include the blood, bone marrow and nervous system. Megaloblastic anemia results from a defect in thymidine and therefore DNA synthesis in rapidly dividing cells. Nervous system involvement is varied, some of which results from defective myelin synthesis and repair. Cognitive impairment and psychosis may also occur. Diagnosis of B12 deficiency rests on clinical suspicion followed by laboratory testing, which consists of a panel of tests, that together provide clinically reliable predictive indices. B12 metabolism and deficiency is closely intertwined with folate, another B-vitamin. This chapter explores the various aspects of a unique and fascinating micronutrient.
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Affiliation(s)
- Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA, United States.
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ, United States
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Paulus MC, Wijnhoven AM, Maessen GC, Blankensteijn SR, van der Heyden MAG. Does vitamin B12 deficiency explain psychiatric symptoms in recreational nitrous oxide users? A narrative review. Clin Toxicol (Phila) 2021; 59:947-955. [PMID: 34348072 DOI: 10.1080/15563650.2021.1938107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Recreational use of nitrous oxide (N2O) is associated with many side effects, of which neurological complications are most common. Nitrous oxide abuse is also associated with psychiatric symptoms, but these have received less attention so far. Vitamin B12 deficiency may play a role in the development of these psychiatric symptoms.Aims To explore the relationship among the occurrence of recreational nitrous oxide-induced psychiatric symptoms, accompanying neurological symptoms, vitamin B12 status and choice of treatment.Methods A retrospective search for case reports was conducted across multiple databases (Pubmed, Embase, Web of Science, PsycINFO and CINAHL). Keywords included variants of "nitrous oxide", "case report" and "abuse". No restrictions to language or publication date were applied.Results The search retrieved 372 articles. A total of 25 case reports were included, representing 31 patients with psychiatric complications following nitrous oxide abuse. The most often reported symptoms were: hallucinations (n = 16), delusions (n = 11), and paranoia (n = 11). When neurological symptoms were present, patients were treated more frequently with vitamin B12 supplementation.Conclusions This review highlights the need to recognize that psychiatric symptoms may appear in association with nitrous oxide use. Approximately half of the cases that presented with nitrous oxide-induced psychiatric complaints did not show neurological symptoms, and their vitamin B12 concentration was often within the hospital's reference range. Psychiatrists and emergency physicians should be aware of isolated psychiatric symptoms caused by recreational nitrous oxide abuse. We suggest asking all patients with new psychiatric symptoms about nitrous oxide use and protocolizing the management of nitrous oxide-induced psychiatric symptoms.
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Affiliation(s)
- Michelle C Paulus
- CRU + Master, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anjali M Wijnhoven
- CRU + Master, University Medical Center Utrecht, Utrecht, The Netherlands
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Zimba S, Chishimba L, Chomba M, Saylor D. Clinical Reasoning: An Unusual Case of Acute Psychosis and Tetraparesis in a Young Zambian Man. Neurology 2021; 97:1002-1005. [PMID: 34233937 DOI: 10.1212/wnl.0000000000012468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Stanley Zimba
- Department of Internal Medicine, University Teaching Hospital; Lusaka, Zambia
| | - Lorraine Chishimba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Mashina Chomba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Deanna Saylor
- Department of Internal Medicine, University Teaching Hospital; Lusaka, Zambia.,Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Sheldon RJG, Reid M, Schon F, Poole NA. Just say N2O – nitrous oxide misuse: essential information for psychiatrists. BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
SUMMARYNitrous oxide (N2O) misuse is widespread in the UK. Although it is well-known that it can cause devastating myeloneuropathy, psychiatric presentations are poorly described. There is little understanding of who it affects, how it presents, its mechanism of action and principles of treatment. We begin this article with a case study. We then review the literature to help psychiatrists understand this area and deal with this increasing problem, and make diagnosis and treatment recommendations. We describe a diagnostic pentad of weakness, numbness, paraesthesia, psychosis and cognitive impairment to alert clinicians to the need to urgently treat these patients. Nitrous oxide misuse is a pending neuropsychiatric emergency requiring urgent treatment with vitamin B12 to prevent potentially irreversible neurological and psychiatric symptoms.
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Abstract
Vitamin B12 and folate deficiencies are major causes of megaloblastic anemia. Causes of B12 deficiency include pernicious anemia, gastric surgery, intestinal disorders, dietary deficiency, and inherited disorders of B12 transport or absorption. The prevalence of folate deficiency has decreased because of folate fortification, but deficiency still occurs from malabsorption and increased demand. Other causes include drugs and inborn metabolic errors. Clinical features of megaloblastic anemia include anemia, cytopenias, jaundice, and megaloblastic marrow morphology. Neurologic symptoms occur in B12 deficiency, but not in folate deficiency. Management includes identifying any deficiency, establishing its cause, and replenishing B12 or folate parenterally or orally.
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Affiliation(s)
- Ralph Green
- Department of Pathology and Laboratory Medicine, UC Davis Medical Center, University of California Davis Health System, 4400 V. Street, Sacramento, CA 95817, USA.
| | - Ananya Datta Mitra
- Department of Pathology and Laboratory Medicine, UC Davis Medical Center, University of California Davis Health System, 4400 V. Street, Sacramento, CA 95817, USA
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Minalyan A, Benhammou JN, Artashesyan A, Lewis MS, Pisegna JR. Autoimmune atrophic gastritis: current perspectives. Clin Exp Gastroenterol 2017; 10:19-27. [PMID: 28223833 PMCID: PMC5304992 DOI: 10.2147/ceg.s109123] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
At present there is no universally accepted classification for gastritis. The first successful classification (The Sydney System) that is still commonly used by medical professionals was first introduced by Misiewicz et al in Sydney in 1990. In fact, it was the first detailed classification after the discovery of Helicobacter pylori by Warren and Marshall in 1982. In 1994, the Updated Sydney System was proposed during the International Workshop on the Histopathology of Gastritis followed by the publication in The American Journal of Surgical Pathology by Dixon et al. Using the new classification, distinction between atrophic and nonatrophic gastritis was revised, and the visual scale grading was incorporated. According to the Updated Sydney System Classification, atrophic gastritis is categorized into multifocal (H. pylori, environmental factors, specific diet) and corpus-predominant (autoimmune). Since metaplasia is a key histological characteristic in patients with atrophic gastritis, it has been recommended to use the word “metaplastic” in both variants of atrophic gastritis: autoimmune metaplastic atrophic gastritis (AMAG) and environmental metaplastic atrophic gastritis. Although there are many overlaps in the course of the disease and distinction between those two entities may be challenging, the aim of this review article was to describe the etiology, epidemiology, pathogenesis, diagnosis, clinical manifestations and treatment in patients with AMAG. However, it is important to mention that H. pylori is the most common etiologic factor for the development of gastritis in the world.
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Affiliation(s)
- Artem Minalyan
- Division of Gastroenterology, Hepatology and Parenteral Nutrition
| | | | - Aida Artashesyan
- Division of Gastroenterology, Hepatology and Parenteral Nutrition
| | - Michael S Lewis
- Department of Pathology and Laboratory Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Joseph R Pisegna
- Division of Gastroenterology, Hepatology and Parenteral Nutrition
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Wells CEC. Symposium on Neurological Abnormalities Found in Association with Various Forms of Macrocytic Anæmia. Proc R Soc Med 2016. [DOI: 10.1177/003591576505800933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kate N, Grover S, Agarwal M. Does B12 deficiency lead to lack of treatment response to conventional antidepressants? PSYCHIATRY (EDGMONT (PA. : TOWNSHIP)) 2010; 7:42-44. [PMID: 21191533 PMCID: PMC3010969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
We present two cases of treatment-resistant depression that improved with recognition and correction of the underlying medical etiology of vitamin B12 deficiency. Supplementations of vitamin B12 to the same antidepressant regimen that the patient had not responded earlier led to response. Two male subjects who were vegetarians presented with long-standing histories of depression and had not responded to three adequate trials of antidepressants. Upon investigation, the authors found that the subjects had low vitamin B12 levels. Both cases improved with supplementation of vitamin B12. Subjects with depression who do not respond to conventional antidepressants should be evaluated for nutritional factors.
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Affiliation(s)
- Natasha Kate
- Ms. Kate is Junior Resident is from the Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
OBJECTIVE Physicians often check folate and cobalamin levels in patients with schizophrenia and depression. The reasons for this practice are reviewed, as well as implications for treatment. METHOD The physiology of the one-carbon cycle, involving folate, cobalamin, homocysteine, S-adenosyl-methionine, and methylene tetrahydrofolate reductase (MTHFR) is first reviewed, and then the particular contributions of folate and B12 are reviewed. PubMed was searched for studies of the association between folate, cobalamin, homocysteine, and MTHFR polymorphisms and schizophrenia and depression. RESULTS The recent key studies from the large literature addressing these topics are summarized. Treatment implications are discussed. CONCLUSION It is important to check folate and B12 levels in certain situations, such as alcoholism, malnutrition, malabsorption, and the concurrent use of some medications. Checking homocysteine and methylmalonic levels might be useful. With respect to treatment, folate and cobalamin deficiencies should be corrected. Cobalamin supplementation is probably not helpful. Folate supplementation is indicated in pregnancy but may exacerbate the effects of cobalamin deficiency. SAMe may prove to be a useful antidepressant. In the future, screening for MTHFR polymorphisms might be useful.
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Affiliation(s)
- Frances Rachel Frankenburg
- Department of Psychiatry, Harvard Medical School, and Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 01730, USA.
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Henkin RI, Hoetker JD. Deficient dietary intake of vitamin E in patients with taste and smell dysfunctions: is vitamin E a cofactor in taste bud and olfactory epithelium apoptosis and in stem cell maturation and development? Nutrition 2004; 19:1013-21. [PMID: 14624956 DOI: 10.1016/j.nut.2003.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES We reviewed dietary intake of several nutrients in a large group of patients with taste and smell dysfunction, compared intake of these nutrients with standard values, and recognized that intake of vitamin E was significantly less than that of most other nutrients. Based on this observation we attempted to develop an hypothesis of the possible role vitamin E might play in these sensory disorders. METHODS Vitamin E intake was measured in 250 patients with taste and smell dysfunctions. RESULTS Intake of the vitamin was 3.2 +/- 0.2 mg/d (mean +/- standard error of the mean), or 36 +/- 2% of the recommended daily allowance, an intake significantly below that considered adequate. This diminished intake occurred with normal intake of total calories; protein; fat; carbohydrate; several vitamins, including thiamin, niacin, and pyridoxine; and the trace metals zinc, copper, and iron. CONCLUSIONS Although specific relations between vitamin E intake and smell and taste dysfunctions are unclear, the non-antioxidant roles of vitamin E indicate that it is a factor in apoptosis, cellular signaling, and growth of various cell lines, suggesting that this vitamin may play a role in growth and development of stem cells in taste buds and olfactory epithelium.
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Affiliation(s)
- R I Henkin
- The Taste and Smell Clinic, Washington, DC 20016, USA.
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Abstract
OBJECTIVE 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.
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Affiliation(s)
- N Berry
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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13
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Abstract
The initial approach to the patient with memory complaints should consist of a focused history, mental status examination, and functional assessment. Patients with MCI should be monitored every 6 to 12 months for conversion to dementia. Delirium, depression, amnestic disorders, and aphasias should be considered in the differential diagnosis of memory impairment. Once a diagnosis of dementia is made, patients should have a brain CT or MRI scan and laboratory tests to assist with determining the cause. It is crucial that dementia be recognized and evaluated at the earliest stage so as to begin appropriate therapy and allow the patient to have a role in management decisions. In the future, therapies for MCI may prevent conversion to dementia. The need for early recognition makes the development of diagnostic tools, such as quantitative or functional neuroimaging, and genetic or clinical biologic markers essential.
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Affiliation(s)
- G Webster Ross
- Honolulu Department of Veterans Affairs, John A. Burns School of Medicine, University of Hawaii, Pacific Health Research Institute, 846 South Hotel Street, Suite 307, Honolulu, HI 96813, USA.
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Herr KD, Norris ER, Frankel BL. Acute psychosis in a patient with vitamin B(12) deficiency and coincident cervical stenosis. PSYCHOSOMATICS 2002; 43:234-6. [PMID: 12075039 DOI: 10.1176/appi.psy.43.3.234] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Keith D Herr
- Department of Psychiatry and Behavioral Sciences, Emory University Hospital, Atlanta, Georgia, USA
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SMITH AD. Veganism: a clinical survey with observations on vitamin-B12 metabolism. BRITISH MEDICAL JOURNAL 1998; 1:1655-8. [PMID: 13914128 PMCID: PMC1958824 DOI: 10.1136/bmj.1.5293.1655] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Catalano G, Catalano MC, Rosenberg EI, Embi PJ, Embi CS. Catatonia. Another neuropsychiatric presentation of vitamin B12 deficiency? PSYCHOSOMATICS 1998; 39:456-60. [PMID: 9775705 DOI: 10.1016/s0033-3182(98)71307-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- G Catalano
- Department of Psychiatry and Behavioral Medicine, University of South Florida College of Medicine, Tampa, USA
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Savage DG, Lindenbaum J. Neurological complications of acquired cobalamin deficiency: clinical aspects. BAILLIERE'S CLINICAL HAEMATOLOGY 1995; 8:657-78. [PMID: 8534966 DOI: 10.1016/s0950-3536(05)80225-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Neuropsychiatric syndromes occur in about 40% of Cbl-deficient patients and are characterized by progressive and variable damage to the spinal cord, peripheral nerves and cerebrum. The first abnormality is usually sensory impairment, most often presenting as distal and symmetrical paraesthesiae of the lower limbs and frequently associated with ataxia. Almost all patients demonstrate loss of vibratory sensation, often in association with diminished proprioception and cutaneous sensation and a Romberg sign. Corticospinal tract involvement is common in more advanced cases, with abnormal reflexes, motor impairment and, ultimately, spastic paraparesis. A minority of patients exhibit mental or psychiatric disturbances or autonomic signs, but these rarely if ever occur in the absence of other neurological changes. Because N2O inactivates Cbl, abuse of the gas may lead to typical Cbl neuropathy. Haematological changes are minimal and serum Cbl levels and Schilling tests normal in most patients. The severity of neurological abnormalities prior to treatment correlates with the duration of symptoms and the haemoglobin level. Initial severity, symptom duration and initial haemoglobin also correlate with residual neurological damage after Cbl therapy. The inverse correlation between severity of anaemia and neurological damage is not understood. Diagnosis of Cbl neuropathy can usually be made in the presence of the typical neuropsychiatric abnormalities, a low serum Cbl level and evidence of megaloblastic haemopoiesis. In some patients serum MMA and HCYS determinations or a therapeutic trial may be required. A neurological response usually occurs within the first 3 months, although further improvement may occur with time. Patients with advanced disease may be left with major residual disability. Therefore early diagnosis is critical. Pharmacological doses of folic acid reverse the haematological abnormalities of Cbl deficiency. This may allow neuropathy to develop or progress and make recognition of deficiency more difficult. There is no clear evidence that folic acid therapy precipitates or exacerbates Cbl neuropathy. Haematological improvement may occur in a fraction of patients receiving small doses of folate, but the data are inadequate to predict the danger of low levels of folate supplementation in the general population.
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Affiliation(s)
- D G Savage
- Department of Haematology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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Abstract
OBJECTIVE The aim of this study was to estimate the levels of vitamin B12 in patients with severe sickle cell disease compared to normal controls. Complete blood count, iron studies and vitamin B12 levels were obtained in 85 consecutive patients with severe sickle cell disease (56 males, 29 females, aged 14-49 years) and 100 healthy blood donors (67 males, 33 females, aged 17-60 years) as a normal control group. RESULTS Thirty-seven of the 85 patients (43.5%) had serum vitamin B12 levels below normal values (mean 84.3 +/- 28.7, range 7-145 pmol L-1) without macrocytosis or hypersegmented neutrophils. The mean level of vitamin B12 in the remaining 48 patients (56.5%) was normal (mean 233.3 +/- 73.9, range 152-435 pmol L-1) which is below the mean of normal control levels (mean 327.7 +/- 168.7, range 178-897 pmol L-1). Patients with low B12 achieved a significant symptomatic improvement when treated with vitamin B12, 1 mg intramuscularly weekly for 12 weeks when compared with patients with normal B12 levels. CONCLUSION We conclude that many patients with severe sickle cell disease may suffer from unrecognized vitamin B12 deficiency.
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Affiliation(s)
- A K al-Momen
- Department of Medicine (38), College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abstract
Psychiatric patients are frequently screened for vitamin B12 deficiency in the absence of hematologic or other neurologic findings. To determine the yield of this practice, 162 psychiatric inpatients were screened for vitamin B12 deficiency. Ten patients had initial low serum vitamin B12 levels, but only two had definite B12 deficiency on further evaluation. Three patients who had initially low B12 levels had normal levels subsequently during outpatient follow-up. When low serum vitamin B12 levels are discovered in psychiatric patients without hematologic or neurologic findings, a diagnosis of B12 deficiency should not be presumed without further evaluation. Key words: screening: psychiatric patients; vitamin B12.
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Affiliation(s)
- A S Brett
- Department of Medicine, New England Deaconess Hospital, Boston, MA 02215
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Kristensen MO, Gulmann NC, Christensen JE, Ostergaard K, Rasmussen K. Serum cobalamin and methylmalonic acid in Alzheimer dementia. Acta Neurol Scand 1993; 87:475-81. [PMID: 8356878 DOI: 10.1111/j.1600-0404.1993.tb04140.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The cobalamin status was evaluated in Alzheimer dementia (n = 26), other dementias (n = 24), various gerontopsychiatric disorders (n = 25), and in neuro-psychiatrically healthy controls (n = 20). Supplementing serum cobalamin we measured methylmalonic acid (MMA), a metabolite accumulating early in cobalamin deficiency. Subnormal cobalamin and/or clearly elevated MMA concentrations were found in 11 cases: 7 Alzheimer patients (27%), 2 with other dementias (8%), one psychiatric patient (4%), and one control (5%). None presented the typical neurologic features of cobalamin deficiency and macrocytosis was found in only one. The mean cobalamin concentration was significantly lower in Alzheimer patients (179 +/- 18 pmol/l) than in the age-matched controls (256 +/- 23 pmol/l) (p = 0.013) and the other patient groups. Correspondingly, the mean MMA level was higher in the Alzheimer group (0.480 +/- 0.062 mumol/l) than in any other diagnostic group (controls: 0.347 +/- 0.040 mumol/l). Comparing the Alzheimer group to the other groups as a whole, the elevation was significant (p = 0.0097). Our findings indicate that Alzheimer patients are particularly prone to cobalamin deficiency, and even subtle biochemical signs of deficiency seem to justify treatment.
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Affiliation(s)
- M O Kristensen
- University Department of Neurology, Aarhus Kommunehospital, Denmark
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22
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Abstract
Cobalamin (vitamin B12) deficiency could be masked by lack of hematological abnormalities or by concomitant conditions associated with microcytosis such as iron deficiency and thalassemia traits. We examined blood and bone marrow morphology, serum ferritin and vitamin B12 levels and fasting gastric pH in nine patients who were suspected to have vitamin B12 deficiency with unusual manifestations. Two patients had neurological symptoms without any hematological abnormalities, two had thalassemia traits, and five had achlorhydria with severe iron and B12 deficiencies. Serum B12 was low in all cases, bone marrow was diagnostic in seven cases and peripheral blood showed hypersegmentation of neutrophils only in five cases. We conclude that vitamin B12 deficiency could be masked by lack of hematological changes or by concomitant causes of microcytosis and that serum vitamin B12 levels as well as other ancillary tests should be considered in all suspected cases.
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Affiliation(s)
- A K Al-Momen
- Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
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Abstract
Potentially reversible dementia is reviewed with reference to diagnosis, causes and outcome. Many disorders which cause cognitive impairment, such as drug toxicity and depression, fail to meet diagnostic criteria for dementia. These tend to have the best prognosis. Studies of the neuropsychiatric syndromes associated with disorders causing potentially reversible dementias suggest that dementia is an infrequent outcome and when it does occur, few cases recover. Factors predictive of improvement are short duration of symptoms and mild degree of cognitive impairment, usually subcortical in type. It is suggested that potentially reversible cognitive impairment would be a more accurate term as many cases are due to delirium and depression. While cases of well established dementia do not require extensive investigation, all cases should have a thorough clinical assessment as in many instances dual pathology exists and all require psychosocial management.
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Affiliation(s)
- B Draper
- Rehabilitation, Age and Extended Care Department, St George Hospital, Kogarah, NSW
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Dommisse J. Subtle vitamin-B12 deficiency and psychiatry: a largely unnoticed but devastating relationship? Med Hypotheses 1991; 34:131-40. [PMID: 2041487 DOI: 10.1016/0306-9877(91)90181-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A long list of psychiatrically inclined illnesses or symptoms, especially some cases of mood disorder, dementia, paranoid psychoses, violent behavior and fatigue, have been documented to be caused by vitamin-B12 deficiency, among other causes. The author uses reputably published literature--and extrapolations from it--to show that these conditions are possibly more commonly caused by B12 deficiency than is currently generally accepted, mostly because of a lack of appreciation of the lowest serum-B12 level that is necessary to protect against the cerebral manifestations of this deficiency. After surveying the whole area of psychiatry and nutritional deficiencies in general, the author deals with the role of vitamin-B12 in mood disorders, paranoid psychoses and dementia in more detail. In doing so, he cites some useful conclusions from the literature, including the debunking of several myths about the diagnosis and treatment of brain-B12-deficiency, especially the efficacy of high dose oral treatment and the relative inefficacy of the Schilling's test.
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Abstract
Evidence for cobalamin (vitamin B12) deficiency usually involves some combination of low serum cobalamin levels, clinical abnormalities (classically, megaloblastic anemia and neurologic defects), metabolic abnormalities, and response to therapy. However, cobalamin deficiency may often display few of the expected clinical findings. Identification of the underlying cause is also important in the diagnosis of deficiency, and its value may be particularly great when the expression of deficiency is subtle. The cause of cobalamin deficiency is usually malabsorptive, but may sometimes be limited to malabsorption of food cobalamin while free cobalamin is absorbed normally. Nongastroenterologic entities may sometimes also be found. All of these considerations allow the proposal of four patterns of cobalamin deficiency. The first type is classical deficiency; typical megaloblastic anemia with or without neurologic dysfunction occurs because of classical cobalamin malabsorption such as lack of intrinsic factor (pernicious anemia). The second type consists of classical cobalamin malabsorption in which the cobalamin deficiency is expressed subtly rather than in classical fashion. There is no megaloblastic anemia and sometimes the only evidence of deficiency may be metabolic. In the third type, cobalamin deficiency is expressed classically but is attributable to a subtle or atypical cause, such as food-cobalamin malabsorption. In the fourth type, deficiency is both expressed subtly and arises from subtle or atypical causes. Such presentations require further investigation but are a challenging expansion of our understanding and recognition of cobalamin deficiency.
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Affiliation(s)
- R Carmel
- Department of Medicine, University of Southern California School of Medicine, Los Angeles 90033
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Abstract
Psychiatric symptoms attributable to vitamin B12 deficiency have been described for decades. The earlier reports are for the most part in accord with more recent ones, despite being diagnostically less specific in psychiatric and hematologic terms. These symptoms seem to fall into several clinically separate categories: slow cerebration; confusion; memory changes; delirium, with or without hallucinations and/or delusions; depression; acute psychotic states; and (more rarely) reversible manic and schizophreniform states. While there still remain abundant hematologic, psychiatric, neurologic, or nutritional reasons for obtaining a serum vitamin B12 level, its use in the investigation of the etiology of a patient's dementia seems unjustified. However, acute or subacute changes in a demented patient's mental status, specifically a clouding of their consciousness, may make such testing advisable as part of the complete workup of their delirium regardless of a normal hematologic picture.
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Affiliation(s)
- M Hector
- Division of Geriatrics, Francis Scott Key Medical Center, Baltimore, MD 21224
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27
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Abstract
When James D. Duke died in 1925, he had left $19 million to build Duke University. He died from pernicious anemia, a vitamin B-12 deficiency. The author gives evidence that Duke made his gift when he was brain damaged and depressed from a vitamin B-12 deficiency, that he donated the money in an attempt to relieve guilt feelings.
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Gross JS, Weintraub NT, Neufeld RR, Libow LS. Pernicious anemia in the demented patient without anemia or macrocytosis. A case for early recognition. J Am Geriatr Soc 1986; 34:612-4. [PMID: 3722679 DOI: 10.1111/j.1532-5415.1986.tb05768.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
It is well known that the neurologic manifestations of vitamin B12 deficiency can occur in the absence of anemia. The authors recently observed two elderly patients who presented to a chronic care institution with the diagnosis of dementia, and in both individuals low serum B12 levels were found in conjunction with abnormal Schilling tests. In neither of these two patients was there anemia or macrocytosis. After receiving parenteral B12 injections there was improvement noted in cognitive functions as well as in activities of daily living. The authors are reporting these patients to alert clinicians to the fact that pernicious anemia in the elderly can first present with low serum B12 levels and neurologic abnormalities in the absence of anemia or macrocytosis.
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Abstract
Organic delusions are common, but have received little systematic study. Review of the literature reveals that they occur most commonly in toxic-metabolic processes and in disorders affecting the limbic system and basal ganglia. A prospective study of 20 consecutive patients with organic delusions revealed four general types of false beliefs: simple persecutory delusions, complex persecutory delusions, grandiose delusions, and those associated with specific neurological defects (anosognosia, reduplicative paramnesia). Simple delusions responded best to treatment, and complex delusions were more resistent. Acting on delusional beliefs was not unusual, and treatment of the delusions was an important aspect of management of the patient.
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Baker H, Frank O, Thind IS, Jaslow SP, Louria DB. Vitamin profiles in elderly persons living at home or in nursing homes, versus profile in healthy young subjects. J Am Geriatr Soc 1979; 27:444-50. [PMID: 469145 DOI: 10.1111/j.1532-5415.1979.tb01724.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Siva Sankar DV. Plasma levels of folates, riboflavin, vitamin B6, and ascorbate in severely disturbed children. J Autism Dev Disord 1979; 9:73-82. [PMID: 438115 DOI: 10.1007/bf01531294] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The recent upsurge in megavitamin therapy raises questions about the role of vitamin deficiencies and dependencies in mental health. With this in mind, the plasma levels of folic acid, ascorbic acid, pyridoxine, and riboflavin were studied in approximately 125 children admitted to a child psychiatric unit. There were no apparent decreased levels of vitamins in these children in terms of their age, race, or psychiatric diagnosis. It is postulated that vitamin deficiencies per se cannot be proposed as etiological factors in any of the psychiatric deficits represented. Megavitamin therapy, if successful, is not effective due to crrection of vitamin deficiencies as opposed to vitamin dependencies and may be due to the metabolic onus and consequent effects of such heavy doses of vitamins.
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Abstract
In an attempt to evaluate the possible relationship between vitamin B12 deficiency and mental disease, the blood content of vitamin B12 was investigated in 835 consecutive psychiatric patients. Low serum vitamin B12 values were found in approximately 10% of these patients, due to latent pernicious anaemia in one case, post-gastrectomy in seven cases and small intestinal resection in one case. In the remaining 72 cases vitamin B12 deficiency was probably caused by nutritional insufficiency. After correction of the dietary defect there was a spontaneous increase in serum vitamin B12 in 75% of these patients. No specific psychiatric syndrome was connected with hypovitaminosis B12, but a preponderance of arteriosclerotic dementia suggests that low serum vitamin B12 values are secondary to mental illness leading to apathy and loss of appetite. Most cases will recover without further vitamin B12 supplements. But some patients may need treatment because of severe mental and physical disabilities.
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34
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Iron Deficiency: Behavior and Brain Biochemistry. Nutrition 1979. [DOI: 10.1007/978-1-4615-7210-7_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Roos D, Willanger R. Various degrees of dementia in a selected group of gastrectomized patients with low serum B12. Acta Neurol Scand 1977; 55:363-76. [PMID: 855644 DOI: 10.1111/j.1600-0404.1977.tb05655.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Forty-two gastrectomized patients (mean age 56 years) with a serum B12 level less than 200 pg/ml were studied by psychological testing and electroencephalography. A total of 50 per cent exhibited mild to moderate or more severe intellectual impairment, judging by the history and psychological testing. EEG abnormalities were found, mainly in the form of reduced dominant activity, in 48 per cent. The results of psychological testing were in accurate conformity with the findings of dementia due to other reasons. The characteristic findings were depression and lability of affect, with a high frequency of suicidal attempts (20 per cent). We interpret the cerebral abnormalities as a result of vitamin B12 deficiency.
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36
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Swallow M. The diagnosis of dementia. A clinical review. Ir J Med Sci 1973; 142:132-40. [PMID: 4541234 DOI: 10.1007/bf02950001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abramsky O. Common and uncommon neurological manifestations as presenting symptoms of vitamin-B12 deficiency. J Am Geriatr Soc 1972; 20:93-6. [PMID: 5008693 DOI: 10.1111/j.1532-5415.1972.tb00776.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
A study is presented of 217 adults referred for psychiatric assessment from the wards of a postgraduate teaching hospital. The pattern of referral and the disproportionate importance of disturbed behaviour amongst referrals from non-medical wards are discussed. The main diagnostic groups, namely, affective disorders, organic states, psychogenic somatic symptoms and attempted suicide, are tabulated and discussed. Complex problems of diagnosis and management were common and are considered under five headings: multiple pathology; the effects of intensive treatment procedures; language and cultural differences, and difficulties in follow-up. It is concluded that the problems met in this specialized setting are likely to become general as intensive treatment and diagnostic procedures become more widespread. The importance of organic reactions is stressed and their relative neglect by both psychiatrists and physicians commented on. The frequency of social precipitants of affective disorders and attempted suicide, however, is considered to emphasize the range of activities required of the psychiatrist in even the most technologically advanced centres.
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Könighaus R, Schäfer J, Tölle R. [Psychoses in B12-avitaminoses without anemia]. ARCHIV FUR PSYCHIATRIE UND NERVENKRANKHEITEN 1971; 214:291-300. [PMID: 5111676 DOI: 10.1007/bf00342631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Waxman S, Corcino JJ, Herbert V. Drugs, toxins and dietary amino acids affecting vitamin B12 or folic acid absorption or utilization. Am J Med 1970; 48:599-608. [PMID: 4912933 DOI: 10.1016/0002-9343(70)90010-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
Considerable interest is at present focused on the possibility of an association between mental illness in epileptics and metabolic abnormalities resulting from the anticonvulsant drugs they have been taking; in fact it has been suggested that these drug-induced abnormalities may be actually causative of the psychiatric disorders. For a good summary of this literature the interested reader is referred to Reynolds (1968).
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Reynolds EH. Schizophrenia-like psychoses of epilepsy and disturbances of folate and vitamin B12 metabolism induced by anticonvulsant drugs. Br J Psychiatry 1967; 113:911-9. [PMID: 6048376 DOI: 10.1192/bjp.113.501.911] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Since it was first described by Mannheimer, Pakesch, Reimer and Vetter in 1952 megaloblastic anaemia has come to be recognized as an occasional complication of anticonvulsant drug therapy. More recently a disturbance in folic acid and vitamin B12metabolism has been observed in many non-anaemic drug-treated epileptic patients (Hawkins and Meynell, 1958; Klipstein, 1964; Malpas, Spray and Witts, 1966; Reynolds, Milner, Matthews and Chanarin, 1966a). Reynoldset al.(1966a) found megaloblastic haemopoiesis in 38 per cent. and subnormal serum folates in over 75 per cent. of a series of 54 out-patient epileptics. In addition, serum vitamin B12levels, though still within the normal range, were significantly lower in the megaloblastic group of patients than in controls. They suggested (1) that the anti-folate effects of phenobarbitone, phenytoin and primidone may be related to their therapeutic actions, and (2) that prolonged drug-induced disturbances of folate and vitamin B12metabolism may be responsible for certain side-effects, particularly mental symptoms. The latter possibility is supported by the increasing recognition of psychiatric illness due to vitamin B12deficiency in the absence of anaemia or subacute combined degeneration of the cord. (Langdon, 1905; McAlpine, 1929; Holmes, 1956; Smith, 1960; Edwin, Holten, Norum, Schrumpf and Skaug, 1965; Strachan and Henderson, 1965).
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Abstract
Many psychiatric symptoms have been described in pernicious anaemia, including depression, manic excitement, paranoid states, confusional episodes, and dementia. Although vitamin B12deficiency is known to produce neurological symptoms there is much less certainty about its role in producing mental symptoms. Despite this uncertainty, it has been asserted that carrying out vitamin B12assays on psychiatric patients will enable doctors to cure for good severe disabling disease which otherwise may end in chronicity (Edwinet al., 1966). Routine examinations to exclude pernicious anaemia have been advocated for all psychiatric patients (Strachan and Henderson, 1965; Hunter and Matthews, 1965). A prudent preliminary is a critical evaluation of the causal relationship between vitamin B12deficiency and individual psychiatric syndromes.
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Reynolds EH, Chanarin I, Milner G, Matthews DM. Anticonvulsant therapy, folic acid and vitamin B12 metabolism and mental symptoms. Epilepsia 1966; 7:261-70. [PMID: 5227261 DOI: 10.1111/j.1528-1157.1966.tb03806.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Herbert V, Gottlieb CW, Altschule MD. Apparent low serum-vitamin-B12 levels associated with chlorpromazine. An artefact. Lancet 1965; 2:1052-3. [PMID: 4159138 DOI: 10.1016/s0140-6736(65)90575-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Wells CE. Clinical neurology of macrocytic anaemia. Proc R Soc Med 1965; 58:721-4. [PMID: 5826212 PMCID: PMC1898890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Mollin DL. The haematological investigation of neurological lesions associated with megaloblastic anaemia. Proc R Soc Med 1965; 58:725-8. [PMID: 5826213 PMCID: PMC1898903 DOI: 10.1177/003591576505800934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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