“I had a nervous breakdown over Christmas”. The callers voice was shaky, trembling almost.
“I’ve phoned you before, you helped me cope, but I’m really bad now, I don’t know how I’m going to carry on”.
It was last Friday that I took that call. I couldn’t remember talking to the lady before, but that didn’t matter, I thought I might be able to help.
“Why am I like this? I can’t seem to cope with everyday life. My doctor says it’s not my PA but I know it is. I’m tired all the time, really tired, and I can’t think straight. I’m doing weird things, saying weird things, talking gibberish. I’m an embarrassment to myself and my family”.

These are the most difficult calls from patients that I have to deal with. Not because of the subject matter, it’s well known that low B12 can have profound effects on the mental health of patients. It’s difficult because the patient’s B12 status will most likely have returned to healthy levels and therefore the physician will dismiss the patient’s behaviour as having nothing to do with his or her Pernicious Anaemia.
I did the best to reassure the caller but in the end the only advice I could give was to ‘take things easy’ – not the greatest comfort for people who are really struggling to carry on their everyday lives.

The next day, Saturday, I woke up in a different frame of mind than I had done for a week. I looked back on the previous week and realised that I too had been experiencing the same awful experience that the previous day’s caller had been experiencing. I had been behaving strangely, oddly, uncharacteristically since the previous Saturday. And yet, at the time, I didn’t know that I was doing odd, bizarre things. I lay awake and recalled some of the odd things that I had done. I’d gone to church to pray, something I had never done before and had been rude to another churchgoer who had asked if I was local. I left the church in a huff and found a small rural church that was not locked and visited it three times during the week; visited it with my camera that I started to carry everywhere (without taking one picture). I was rude to callers, and used inappropriate language. I started writing the strangest stories that were pure fiction. I was morose, to the extent that, when taking my regular weekly walk with two ex-colleagues, they both asked what was wrong. I thought the world was wrong and I was right. I ate junk food and only junk food, and started stating the most bizarre facts that were anachronistic and totally out of context to any conversation I might have had. It was as if I was still waiting to be diagnosed and treated.

And this is the strange thing. I am swimming in B12. So why do I still get these episodes where I change into a different person, showing all the symptoms of the psychiatric symptoms of a person with low B12?
The answer is that nobody knows though it has been suggested that it’s due to lesions to my brain that were caused when I was severely deficient in Vitamin B12, and that means that no matter what I do, I will still carry on to have these episodes where my behaviour reverts to how I was just before being diagnosed.
I can’t remember when I had a week like this before, but it must have been over two years ago when I dismissed all of the volunteers working for the charity within an hour of turning up at the office (they returned in the next few days I’m glad to say after I had tried to explain why I had acted as I did). Hopefully it will be another two years or more before I experience it again.

The worst part of these episodes is that I’m not aware that I am doing anything odd; I’m convinced that I am doing the right things and that others are doing the wrong things. It leads to unprofessional behaviour (I remember screaming at post-graduate students in the corridor of the university where I was teaching just before being diagnosed) and inappropriate things being said. Yet I think it perfectly normal behaviour; behaviour that is completely out of character for me.

This leads me on to believe that the B12 status of every patient involved in psychiatric care should be checked. And I’m not alone.
A recently published paper by a team of doctors in Saudi Arabia shows I’m not alone.
Here’s how the patient was described:
‘the patient became more aggressive, had reduced sleep, had stopped going to work, and became isolated. He also had hallucinations and episodes of short term
memory loss’.

And this is what they note:
‘Neuropsychiatric manifestations of vitamin B12 deficiency include dementia, delirium, cerebellar ataxia, psychosis, neuropathy, and mood disorders. Acute
delirium is rarely the only presenting symptom. In our case, acute delirium preceded the typical haematological and neurological findings observed in vitamin B12 deficiency’.

And they go on to recommend:
‘There are multiple factors that lead to misdiagnosis of vitamin B12 deficiency. Most physicians are not aware that psychiatric symptoms may sometimes be the only presenting symptoms of vitamin B12 deficiency. Most doctors depend on MCV and MCH values to diagnose vitamin B12 deficiency. However, perturbations in MCV and MCH are late signs of vitamin B12 deficiency. In addition, the serum vitamin B12 test is not very sensitive or specific. At the same time, serum vitamin B12 levels need not to be very low in order to produce psychiatric symptoms’.
Let’s cherry pick from that paragraph:
‘psychiatric symptoms may sometimes be the only presenting symptoms of vitamin B12 deficiency’

And:
‘At the same time, serum vitamin B12 levels need not to be very low in order to produce psychiatric symptoms’
And that could be the reason why the telephone caller and I still experience the psychiatric symptoms even though our B12 levels are satisfactory – whatever that means.
What is going on?

Ref: Hani Almoallim, Fahtima S.Mehdawi, Mohammed M.Cheikh, Fahmi Al-dhaheri, AbdullahMahir Aqeel: Reversible Vitamin B12 Deficiency Presenting with Acute Dementia, Paraparesis, and Normal Hemoglobin; Case Reports in Neurological Medicine,Volume 2016, Article ID 4301769, 3 pages