BEN'S STORY (Continued): I decided to start with the psychosocial stressors - (being a
parent, having an ill wife and parents) and delve into the nature of how these stressors changed his life, and how he adapted to them. Apparently, Benjamin had to take a detour from his own
career in order to manage his parents finances, control his mothers spending, and deal with his fathers business. When the day was done, he would come home to his ill wife and do most of the house work. Having little support, Benjamin began to cope by stress-eating. He gained weight, began to experience indigestion, and excessive belching. His family doctor, concerned about gastro-esophageal reflux, placed him on Prilosec. Benjamin noticed a significant improvement in his indigestion and remained on the drug for three years before his present
panic attacks and depression recurred. However, now the recurrence of panic shook his confidence and he felt that he was losing control of his life and his mind, once again.
THE PARADIGM: Knowing that Prilosec could inhibit B12 absorption, (it inhibits the very cells that produce intrinsic factor, which is necessary for B12 absorption), I eventually convinced Benjamin that he should be worked up for a B12 deficiency secondary to the Prilosec. Despite his distress, he was quite resistant to this idea. The detection of B12 deficiency is difficult. One can look for a macrocytic anemia (large red blood cells also called high MCV), low serum B12 levels, or high levels of methylmalonic acid. However, a number of studies indicate that these tests are often falsely normal when tested against the gold standard Schillings test (no longer available).
Martin Seligman's learned helplessness model of depression demonstrates that despite their pain, some depressed individuals actively resist help. The neurophysiology of mood disorders suggests that a certain part of the prefrontal cortex (the ventromedial prefrontal cortex) whose function is to accurately predict or anticipate rewarding experiences and pleasure, or painful consequences, has reduced activity.
Because Benjamin complained of indigestion, bloating, constipation, and gassiness, I also evaluated him for bacterial overgrowth of the small intestine which can impair nutrient absorption. An IgG panel for delayed food sensitivities, a comprehensive digestive stool analysis, and an adrenal saliva test rounded out the work up.
BEN'S STORY: When he finally agreed to the workup (one year later), he indeed turned out to have a B12 deficiency. His methylmalonic acid and CBC were within normal limits, although his MCV was trending to the upper limit of normal, and his red blood cell count was trending toward anemia. These trends indicated that a macrocytic anemia was developing, but that the effects of the B12 deficiency manifested themselves first in Benjamin's weakest system-his nervous system. The only test that was abnormal was a functional intracellular assay of B12 function. With the introduction of B12 injections Benjamin's panic and depression cleared completely.
The next two tasks were to help Benjamin address the stressors in his life, and his stress-eating response. Based on the test results a number of dietary changes, a program to rebalnce his gastrointestinal milieu, nutritional support, as well as meditation and a regular exercise program were instituted. Benjamin lost weight, discontinued the Prilosec, and felt more in control of his life. He has been without panic or depression since then (8+ year follow up).
I saw Ben last week, and he told me "I am at a high point in my life." Many of his career aspirations were coming to fruition, and family stresses were becoming more manageable as his attitude was maturing. Is this just a nice, sugar coated story with a happy ending, or are there lessons to be learned from Ben's difficult passage? You decide.
(Adapted with modification from: Depression: Advancing the Treatment Paradigm, Robert J. Hedaya, MD, FAPA, 2008. IFM.ORG)
