Problem 1 Failure to recognize the neurological and psychiatric symptoms of B12 deficiency

The number one reason for the high rate of missed diagnoses is that physicians fail to recognize the neuropsychiatric signs and symptoms of B12 deficiency. It is well known and has been well documented that B12 deficiency damages the brain, spinal cord, peripheral nerves, and the nerves of the eye, often well before blood abnormalities appear. Thus, doctors who think of B12 deficiency only in the context of anemia will miss the majority of cases that pass through their offices and hospitals. Physicians must become aware that macrocytic anemia is a late sign of vitamin Bu deficiency, frequently occurring long after potentially irreversible neurological damage has taken place.

The common and striking neuropsychiatric manifestations of B12 deficiency, including depression, altered mental status, dementia, psychosis, vertigo, tremor, neuropathy, visual problems, extremity weakness, dizziness, balance problems, and gait disorders, have been long forgotten by

In our experience, there are eight reasons why physicians often miss a diagnosis of B]2 deficiency.

physicians. This is perplexing, because physicians as far back as 190 years ago—Combes (1820), Addison (1855), and Biermer (1872)—documented that "pernicious anemia" caused severe neurologic complications. Later, physicians Osler (1877), Lichtheim (1887), and Cabot (1908) reported on post-mortem exams of pernicious anemia patients revealing subacute combined degeneration of the spinal cord. An array of published medical articles exist describing neurologic symptomatology preceding the classic blood signs, yet clinicians ignore or have forgotten this and, rather than testing for B12 deficiency, simply prescribe other medications in an attempt to alleviate their patients' symptoms.

In 1988, Lindenbaum et al. reported in the New England Journal of Medicine that neurologic manifestations associated with B12 deficiency occurred in the absence of anemia or macrocytosis. This article generated a great deal of interest and was interpreted as new information, which it clearly was not. It is evident that the knowledge of B12 deficiency as a cause of neurologic and/or psychiatric disease has been lost.

Identifying the Symptoms of B12 Deficiency

B12 deficiency affects all body systems, is a master mimic, and can masquerade as a wide variety of medical problems. In addition to neuropsychiatry manifestations, it can cause shortness of breath, fatigue, generalized weakness, anemia, poor digestion, GERD-like symptoms, constipation, diarrhea, weight loss, recurrent miscarriage, abnormal pap smears, infertility, osteoporosis, poor wound healing, and poor immune response. Patients with B12 deficiency may have few or subtle signs, or present with a wide variety of overt signs and symptoms that are easy to blame on other disorders, preexisting diseases and comor-bid conditions.

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