module B55 relief and nutrition in disasters, crises and for populations at risk: hunger – a global challenge eating disorders and biological short introduction into psychiatric symptomatology major (psychotic type) bipolar , manic phase (depressive symptoms) obsessive-compulsive with •loss of contact with reality •hallucinations • •flattened affect •cognitive deficits •and social dysfunction : loss of contact with reality? hallucinations? delusions? flattened affect? cognitive deficits? and social dysfunction?

Mortality and recovery rates

Without treatment, up to twenty percent (20%) of people with serious eating disorders die.

With treatment, that number falls to two to three percent (2-3%). In 2005, Dr. Wright of the Eating Disorders Program at Presbyterian Hospital in Dallas, Texas indicated that the mortality rate for untreated anorexia nervosa may be even higher, up to 25 percent.

source: With treatment, about sixty percent (60%) of people with eating disorders recover. They maintain healthy weight. They eat a varied diet of normal foods and do not choose exclusively low-cal and non-fat items.

They participate in friendships and romantic relationships. They create families and careers.

Many say they feel they are stronger and more competent in life than they would have been if they had not developed confidence in themseles by conquering the disorder. In spite of treatment, about twenty percent (20%) of people with eating disorders make only partial recoveries.

They remain too much focused on food and weight. They participate only superficially in friendships and romantic relationships. They may hold jobs but seldom have meaningful careers. Much of each paycheck goes to diet books, laxatives, jazzercise classes, and binge food.

The remaining twenty percent (20%) do not improve, even with treatment. They are seen repeatedly in emergency rooms, eating disorders programs, and clinics. Their routinely desperate lives revolve around food and weight concerns, spiraling down into depression, anxiety loneliness, and feelings of helplessness and hopelessness. Eating disorders in Western and non-Western countries

In a study reported in Medscape's General Medicine 6(3) 2004, prevalence rates in Western countries for anorexia nervosa ranged from 0.1% to 5.7% in female subjects. Prevalence rates for ranged from 0% to 2.1% in males and from 0.3% to 7.3% in female subjects.

Prevalence rates in non-Western countries for bulimia nervosa ranged from 0.46% to 3.2% in female subjects.

Studies of eating attitudes indicate abnormal eating attitudes in non- Western countries have been gradually increasing, presumably because of the influence, at least in part, of Western media: movies, TV shows, and magazines. Researchers conclude that the prevalence of eating disorders in non-Western countries is lower than that of Western countries, but it appears to be increasing. The better-known eating disorders Anorexia nervosa: the relentless pursuit of thinness

Person• refuses to maintain normal body weight for age and height.

Weighs• 85% or less than what is developmentally expected for age and height.

Young• girls do not begin to menstruate at the appropriate age. Puberty is delayed

in• both sexes.

In• women, menstrual periods stop. In men, levels of sex hormones fall. Sex drive disappears

or• is much diminished.

Person• denies the dangers of low weight.

Is• terrified of becoming fat.

I• s terrified of gaining weight even though s/he is alarmingly .

Reports• feeling fat even when emaciated.

In• addition, anorexia nervosa often includes depression, irritability, withdrawal, and peculiar behaviors such as compulsive rituals, strange eating habits, and division of foods into "good/safe" and "bad/dangerous" categories. Person may have low tolerance for change and new situations; may fear growing up and assuming adult responsibilities and an adult lifestyle. May be overly engaged with or dependent on parents or family. Dieting may represent avoidance of, or attempts to cope with, the demands of a new life stage such as adolescence or adulthood. Bulimia nervosa: the diet-binge-purge disorder

Person• diets, becomes hungry, and then binge eats in response to powerful

cravings• and feelings of deprivation.

Feels• out of control while eating.

Fears• gaining weight and frantically tries to "undo" the binge. Vomits, abuses laxatives,

• exercises, or fasts to get rid of the calories.

Swears• to "be good," to never binge eat again, but then continues to restrict food intake which starts yet another repeat of the deprivation-hunger-binge-purge cycle.

Believes• self-worth requires being thin. (It does not.)

May• shoplift, be promiscuous, and abuse , drugs and credit cards. May engage in risk-taking behavior and have other problems with impulse control. Person acts with little thought of consequences.

Weight• may be normal or near normal unless anorexia is also present.

Like• anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely, ashamed, and empty inside. Friends may describe them as competent, glamorous, adventurous and fun to be with, but underneath, where they hide their guilty secrets, they are hurting. Feeling unworthy, they have great difficulty talking about their feelings, which almost always include anxiety, depression, self-doubt, and deeply buried anger. Binge

The• person binge eats large amounts of food frequently and repeatedly.

Feels• out of control and unable to stop eating during binges.

May• eat rapidly and secretly, or may snack and nibble all day long.

Feels• guilty and ashamed of binge eating.

Has• a history of diet failures

Tends• to be depressed and obese.

People• who have binge eating disorder do not regularly vomit, overexercise, or abuse laxatives like bulimics do. They may be genetically predisposed to weigh more than the cultural ideal (which at present is exceedingly unrealistic), so they diet, make themselves hungry, and then binge in response to that hunger.

Or they may eat for emotional reasons: to comfort themselves, avoid threatening situations, and numb emotional . Regardless of the reason, diet programs are not the answer. In fact, diets almost always make matters worse. Information reported in the March 2003 New England Journal of Medicine suggests that for some people, but not all, a genetic flaw in combination with lifestyle factors can predispose to binge eating and subsequent obesity. ED-NOS: Eating disorders not otherwise specified

An• official diagnosis. The phrase describes atypical eating disorders.

Includes• situations in which a person meets all but a few of the criteria for a particular diagnosis.

What• the person is doing with regard to food and weight is neither normal nor healthy. Less-well-known eating disorders and related problems Purging disorder

Not• yet a formal diagnosis, but seems to be separate from bulimia nervosa. At present, falls into the category of "Eating disorder not otherwise specified: EDNOS."

The• person purges (vomits, abuses laxatives, , emetics, etc.) but does not binge eat.

Person• maintains normal or near normal weight.

Researchers• suspect that purging disorder may be more common than anorexia nervosa and bulimia combined.

There• is a scholarly discussion of purging disorder in the International Journal of Eating Disorders 2005; 38:191- 100. A public librarian or a research librarian in your school or local hospital can tell you how to obtain a copy. Anorexia athletica (compulsive exercising)

Not• a formal diagnosis. The behaviors are usually a part of anorexia nervosa, bulimia, or obsessive-compulsive disorder.

The• person repeatedly exercises beyond the requirements for good health.

May• be a fanatic about weight and diet.

Steals• time to exercise from work, school, and relationships.

Strives• to achieve and master ever more difficult challenges. Forgets that physical activity can be fun.

Defines• self-worth in terms of performance

Is• rarely or never satisfied with athletic achievements. Small satisfactions are fleeting. Does not savor victory but pushes on to the next challenge immediately.

Justifies• excessive behavior by defining self as a dedicated or elite athlete.

Compulsive• exercising is not an official diagnosis as are anorexia, bulimia, and binge eating disorder. We include it here because many people who are preoccupied with food and body size exercise compulsively in attempts to control weight. The real issues are not weight and performance excellence but rather control and self-respect. For more information, go to Athletes With Eating Disorders and Males and Females and Obligatory Exercise

People• with BDD are excessively concerned about appearance, in particular perceived flaws of face, hair, and skin. They are convinced these flaws exist in spite of reassurances from friends and family members who usually can see nothing to justify such intense worry and anxiety.

The• person with an eating disorder says, "I am so fat." The person with BDD says, "I am so ugly."

BDD• often includes social . Sufferers are shy and withdrawn in new situations and with unfamiliar people.

BDD• affects about two percent of the people in the United States. It strikes males and females equally. Seventy percent of cases appear before age eighteen.

BDD• sufferers are at elevated risk for despair and suicide. In some cases they undergo multiple, unnecessary plastic surgeries.

BDD• is thought to be a subtype of obsessive-compulsive disorder. It is not a variant of anorexia nervosa or bulimia nervosa.

BDD• is treatable and begins with an evaluation by a physician and mental health care provider. Treatments thus far found to be effective include medication (especially meds that adjust levels in the ) and cognitive-behavioral therapy. A clinician makes the diagnosis and recommends treatment based on the needs and circumstances of each person. Muscle dysmorphic disorder (bigorexia)

A• subtype of body dysmorphic disorder, described above.

Sometimes• called "bigorexia," muscle dysmorphia is the opposite of anorexia nervosa. People with this disorder obsess about being too small and undeveloped. They worry that they are too little and too frail. Even if they have good muscle mass, they believe their muscles are inadequate.

We• have more information about muscle dysmorphic disorder on another page in this site. -triggered, auto immune subtype of anorexia nervosa in young children

Not• an official eating disorder, but the topic has gathered the interest of researchers.

May• be related to a type of obsessive-compulsive disorder triggered by an auto immune process initiated by bacteria or that have attacked parts of the nervous system.

May• be related to pediatric infection-triggered auto immune neuropsychiatric disorders (PITANDS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS).

Suspected• when symptoms and behaviors typical of anorexia nervosa appear suddenly in a young child, or when symptoms and behaviors in a young child worsen quickly with no other explanation.

And• when the child has had a recent respiratory, throat, or other infection.

Antibiotics,• antivirals, and/or vaccines may be part of the treatment, either after refusal to eat appears or as prevention.

The• first step in treatment is a thorough evaluation done by a pediatrician who is familiar with PITANDS and PANDAS research.

Reference• for physicians: Journal of the American Academy of Child and Adolescent Psychiatry, Volume 36, Number 8. Orthorexia nervosa

Not• an official eating disorder diagnosis, but the concept is useful. The name was coined by Steven Bratman, M.D., to describe "a pathological fixation on eating 'proper' or 'pure' or 'superior' food." In everyday language, orthorexia is an unhealthy fixation on healthy eating.

People• with orthorexia nervosa feel superior to others who eat "improper" food, which might include non-organic or fun foods and items found in regular grocery stores, as opposed to health food stores.

Orthorexics• obsess over what to eat, how much to eat, how to prepare food "properly," and where to obtain "pure" and "proper" foods.

Eating• the "right" food becomes an important ,or even the primary, focus of life. One's worth or goodness is seen in terms of what one does or does not eat. Personal values, relationships, career goals, and friendships become less important than the quality and timing of what is consumed.

Perhaps• related to, or a type of, obsessive-compulsive disorder Night-eating

The• person has little or no for breakfast. Delays first meal for several hours after waking up. Is often upset about how much was eaten the night before.

Most• of the day's calories are eaten late in the day or at night.

We• have more information about night-eating syndrome on another page in this site. Nocturnal sleep-related eating disorder

Thought• to be a , not an eating disorder

Person• eats while asleep or in a semi-conscious state. Has little or no of episode the next day and may be embarrassed or horrified to find evidence of behavior.

May• also sleep walk.

We• have more information about nocturnal sleep-related eating disorder on another page in this site. Gourmand syndrome

Person• is preoccupied with fine food, including its purchase, preparation, presentation, and consumption. S/he is less engaged than previously with friends, family, job, and other activities.

Gourmand• syndrome is very rare. Only 34 cases have been reported in medical literature. It is thought to be caused by to the right side of the brain -- tumor, , , etc.

Some• symptoms overlap with obsessive-compulsive and addictive disorders.

In• spite of their "lusting after food" and enthusiastic consumption of it, people with gourmand syndrome do not seem to become fat. Nor do they vomit, abuse laxatives, or engage in other pathological weight-loss behaviors. They had normal relationships with food before the brain injury.

Cognitive,• behavioral, and motor impairments are common, probably also related to the brain injury. People are not particularly troubled by their new consuming interest.

Treatment• should begin with a neurologist or possibly a psychiatrist. Prader-Willi syndrome

A• congenital problem usually associated with mental retardation and difficult behavior problems. Chief symptom is an implacable drive to eat constantly that will not be denied.

We• have more information about Prader-Willi syndrome on another page in this site.

• A craving for non-food items such as dirt, clay, plaster, chalk, or paint chips.

We• have more information about pica on another page in this site. Cyclic vomiting syndrome

Cycles• of frequent vomiting. Usually (but not always) a problem found in children.

May• be related to, or share neurological mechanisms with, migraine .

We• have more information about cyclic vomiting syndrome on another page in this site. Chewing and spitting

The• person puts food in his/her mouth, tastes it, chews it, and then spits it out.

Some• people believe this behavior is a separate eating disorder. It is not. It is a calorie-control strategy commonly seen in anorexia nervosa, and sometimes in bulimia and eating-disorder-not-otherwise-specified. The person is creative, allowing some experience and enjoyment of food but avoiding all but a few calories. Since essential nutrients are not incorporated into the body, chewing and spitting can be just as harmful to health as are starvation dieting and binge eating followed by purging. Medical and psychological complications of eating disorders Medical problems

If not stopped, starving, stuffing, and purging can lead to irreversible physical damage and even death. Eating disorders can affect every cell, tissue, and organ in the body. The following is a partial list of the medical dangers associated with anorexia nervosa, bulimia, and binge eating disorder. Irregular heartbeat, , death

Kidney damage, renal failure, death

Liver damage (made worse by ), death

Loss of muscle mass. Broomstick arms and legs.

Permanent loss of bone mass; fractures and lifelong problems caused by fragile bones and joints. Osteopenia, osteoporosis, and dowager's hump

Destruction of teeth, rupture of esophagus, damage to lining of stomach; , gastric distress including bloat and distension

Disruption of menstrual cycle, infertility (see below)

Delayed growth and permanently due to under-nutrition. Even after recovery and weight restoration, person may not catch up to expected normal height.

Weakened immune system

Icy hands and feet Swollen• glands in neck; stones in salivary duct, "chipmunk cheeks."

Excess• hair on face, arms, and body. Long, downy lanugo hair that may be an emaciated body's attempt to be warm.

Dry,• blotchy skin that has an unhealthy gray or yellow cast

Anemia,• . Disruption of body's fluid/mineral balance (, loss of potassium; can be fatal)

Fainting• spells, seizures, sleep disruption, bad dreams, mental fuzziness

Low• blood sugar (hypoglycemia), including shakiness, anxiety, restlessness, and a pervasive itchy sensation all over the body.

Anal• and bladder incontinence, urinary tract , vaginal prolapse, and other problems related to weak and damaged pelvic floor muscles. Some problems may be related to chronic constipation, which is commonly found in people with anorexia nervosa. Structural damage and of pelvic floor muscles can be caused by low estrogen levels, excessive exercise, and inadequate nutrition. Surgery may be necessary to repair the damage.

Because• of changes in the brain associated with under-nourishment, binge eating, and purging, the person does not, and perhaps cannot, weigh priorities, make judgments, and make choices that are logical and rational for normal people. Recovery, once the process has begun, requires time for the brain to readjust -- chemically and physically -- to normal and healthy patterns of eating. This is a combined physical/psychological problem. Psychological problems

As painful as the medical consequences of an eating disorder are, the psychological agony can be worse. It is a sad irony that the person who develops an eating disorder often begins with a diet, believing that will lead to improved self-esteem, self- confidence, and happiness. The cruel reality is that persistent undereating, binge eating, and purging have the opposite effect. Eating disordered individuals typically struggle with one or more of the following complications: Depression• that can lead to self-harm and suicide

Person• feels out of control and helpless to do anything about problems

Anxiety,• self-doubt

Guilt• and shame, feelings of failure

Hypervigilance. Thinks other people are watching and waiting to confront or interfere.

Fear• of discovery

Obsessive• thoughts and preoccupations

Compulsive• behaviors. Rituals dictate most activities.

Feelings• of alienation and loneliness. "I don't fit in anywhere."

Feels• hopeless and helpless. Cannot figure out how to make things better. May give up and sink into despair, fatalism, or suicidal depression.

Because• of changes in the brain associated with under-nourishment, binge eating, and purging, the person does not, and perhaps cannot, weigh priorities, make judgments, and make choices that are logical and rational for normal people. Recovery, once the process is begun, requires time for the brain to readjust -- chemically and physically -- to normal and healthy patterns of eating. This is a combined physical/psychological problem.

Compr Psychiatry 1997 Nov-Dec;38(6):305-14

Folate and cobalamin in psychiatric illness. Hutto BR Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, 27599, USA.

The linkage of cobalamin and to psychiatric illness has been studied and debated since these were first discovered in the 1940s.The clinical relevance of these deficiencies remains the subject of investigation and scholarly discussion. This article reviews case reports andstudies derived from a MEDLINE search for English-language articles related to folate, cobalamin, and psychiatric illness. Emphasis is given to clinical research and recent developments. Preclinical evidence for direct effects of folate and cobalamin on brain functioning is compelling, and numerous associations of their deficiencies to psychiatric illness are evident. These deficiencies may typically present initially with psychiatric symptoms, but any direct causal relationship to specific neuropsychiatric illnesses are not well defined. The relationship of these vitamins in is significant, but they may only rarely be a cause of truly reversible dementia. Folate deficiency appears most tightly connected with depressive disorders, and cobalamin deficiency with psychosis. Contrary to intuition, vitamin deficiencies appear to occur infrequently with eating disorders. Other diagnoses have been investigated much less extensively. The diagnosis and management of these deficiencies in the context of neuropsychiatric illness is still a matter of discussion. The quality of clinical research in this area is improving, but there are many unanswered questions that affect clinical practice. Clinicians should remain vigilant to the possibility of deficiencies of folate and cobalamin in diverse psychiatric populations. Normal hematological indices do not rule out the deficiencies. Further study is needed to refine the detection and clinical management of these vitamin deficiencies in psychiatric populations. Nutr Rev 1997 May;55(5):145-9

Nutrition and depression: the role of folate.

Alpert JE, Fava M

Department of Psychiatry, Harvard Medical School, Boston, MA 02114, USA.

A relationship between folate and neuropsychiatric disorders has been inferred from clinical observation and from the enhanced understanding of the role of folate in critical brain metabolic pathways. Depressive symptoms are the most common neuropsychiatric manifestation of folate deficiency. Conversely, borderline low or deficient serum or red blood cell folate levels have been detected in 15-38% of adults diagnosed with depressive disorders. Recently, low folate levels have been linked to poorer response to selective serotonin reuptake inhibitors. Factors contributing to low serum folate levels among depressed patients as well as the circumstances under which folate andits derivatives may have a role in antidepressant pharmacotherapy must be further clarified. Nutr Rev 1996 Dec;54(12):382-90

Folate, vitamin B12, and neuropsychiatric disorders.

Bottiglieri TKimberly H. Courtwright and Joseph W. Summers

Institute of Metabolic ,Baylor University Medical Center, Dallas, Texas, USA.

Folate and vitamin B12 are required both in the methylation of homocysteine tomethionine and in the synthesis of S-adenosylmethionine. S- adenosylmethionineis involved in numerous methylation reactions involving proteins,phospholipids, DNA, and metabolism. Both folate and may cause similar neurologic and psychiatric disturbances including depression, dementia, and a demyelinating myelopathy. A current theory proposes that a defect in methylation processes is central to thebiochemical basis of the neuropsychiatry of these vitamin deficiencies. Folate deficiency may specifically affect central monoamine metabolism and aggravate depressive disorders. In addition, the neurotoxic effects of homocysteine may also play a role in the neurologic and psychiatric disturbances that are associated with folate and vitamin B12 deficiency. Med Hypotheses 1991 Feb;34(2):131-40

Subtle vitamin-B12 deficiency and psychiatry: a largely unnoticed butdevastating relationship?

Dommisse J A long list of psychiatrically inclined illnesses or symptoms, especially some cases of , dementia, paranoid psychoses, violent behavior and , 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. Nutr Rev 1989 Jul;47(7):208-10

Unrecognized cobalamin-responsive neuropsychiatric disorders.

Neuropsychiatric disorders due to cobalamin deficiency occur in the absence of or significant macrocytosis and may be overlooked because usual clinical laboratory tests are unreliable for diagnosis of cobalamin deficiency. Serummethylmalonic acid and homocysteine levels appear to be sensitive and accurate markers of cobalamin deficiency. Biol Psychiatry 1989 Apr 1;25(7):867-72

Folate, B12, and life course of depressive illness.

Levitt AJ, Joffe RTDepartment of Psychiatry, University of Toronto, Ontario, Canada.

Forty-four consecutive, unmedicated outpatients with a major depressive disorder were evaluated to determine the relationships in life course, severityof depressive illness, and serum folate and B12 levels. Duration of currentepisode was significantly inversely correlated with folate levels. Age at onsetof illness was significantly correlated with B12. In a subgroup of recurrent depressives, current age and age at onset of depressive illness were positively correlated with folate. The findings are discussed in light of the current hypotheses regarding the association of folate and mood. J Psychiatr Res 1986;20(2):91-101

The biology of folate in depression: implications for nutritional hypotheses of the psychoses.

Abou-Saleh MT, Coppen A

Folate deficiency is a common occurrence in psychiatric disorders, whether organic or functional, particularly in depressive illness. We have shown that folate deficiency is a common association of depressive symptoms in a variety of settings including primary endogenous or non- endogenous depression, and in alcoholic, -treated and anorexic patients. Possible pathogenetic mediating mechanisms for this association are methylation and hydroxylation and the implications for nutritional hypotheses of the psychoses are discussed. We suggest that folate deficiency, with or without deficiencies of other nutritional factors such as monoamine precursors, vitamins B6, B12 and C, may predispose to or aggravate psychiatric disturbances, particularly depression and a model for these interactions is proposed. Biol Psychiatry 1981 Feb;16(2):197-205

B12 deficiency and psychiatric disorders: case report and literature review.

Zucker DK, Livingston RL, Nakra R, Clayton PJ

Although an association of psychiatric symptoms with vitamin B12 deficiency is well accepted, the incidence and nature of these symptoms is not established. To help illuminate the natural history of this illness we review the literature regarding associated with B12 deficiency and examine 15 cases, including one of our own, that meet specified criteria for B12-responsivepsychosis. In the accepted cases the most common psychiatric symptoms were organic brain syndrome, , violence, and depression. Several of the patients were not anemic and had no neurologic deficit. Examination of bloodsmears or obtaining of serum B12 levels should be considered for patients with the symptoms described. Prog Neuropsychopharmacol Biol Psychiatry 1989;13(6):841-63

Folic acid and psychopathology.

Young SN, Ghadirian AM

Department of Psychiatry, McGill University, Montreal, Quebec, Canada

.1. The incidence of folic acid deficiency is high in patients with various psychiatric disorders including depression, dementia and schizophrenia. 2. In epileptics on anticonvulsants, folate deficiency often occurs because anticonvulsants inhibit folate absorption. In these patients folate deficiencies often associated with psychiatric symptoms. 3. In medical patients psychiatric symptoms occur more frequently, and in psychiatric patients symptoms are more severe, in those with folate deficiency than in those with normal levels. 4. Many open studies have demonstrated therapeutic effects of folate administration on psychiatric symptoms in folate deficient patients. 5.Several placebo-controlled studies have not demonstrated therapeutic effects,possibly because the doses they used (15-20 mg/day) are known to be toxic andto cause mental symptoms. 6. Two placebo-controlled studies have demonstrated beneficial effects of folic acid administration, one in patients with a syndrome of psychiatric and neuropsychological changes associated with folate deficiency and the other in patients on long-term lithium therapy. In the latter study the dose was only 0.2 mg/day. 7. Folic acid deficiency is known to lower brain S- adenosylmethionine and 5-hydroxytryptamine. S-Adenosylmethionine,which has antidepressant properties, raises brain 5-hydroxytryptamine. Thus,depression associated with folate deficiency is probably related to low brain 5HT. 8. S-Adenosylmethionine is involved in many methylation reactions,including methylation of membrane phospholipids, which influences membrane properties. This may explain the wide variety of symptoms associated with folate deficiency. 9. Because the costs and risks associated with low doses of folic acid (up to 0.5 mg/day) are small, folic acid should be given as an adjunct in the treatment of patients with unipolar or bipolar affective disorders and anorexia, epileptics on anticonvulsants, geriatric patients with mental symptoms and patients with gastrointestinal disorders who exhibit psychiatric symptoms. 10. Although the majority of the patients listed above will probably not be helped by folic acid therapy, a significant minority are likely to have folate-responsive symptoms.