Tuesday, August 30, 2011

Celiac and psychiatric disorders

I actually wrote this for my professional organizations newsletter. I didn't get a whole lot of space so I kept it quite concise. The chart was not included in the letter but I think it is important.


Psychiatric manifestations of gluten sensitivity/celiac disease and why it is important to psychiatric providers

The spectrum of gluten sensitivity to celiac disease is caused by a molecule contained in wheat, rye, barley and through cross-contamination on oats. These disorders are commonly associated with the gut but current research suggests they may be more likely to manifest as psychiatric conditions. These include but are not limited to schizophrenia, depression, attention deficit, and autism spectrum. Celiac disease is up to 25% more prevalent in people with psychiatric disorders [i]. People suffering from these conditions often initially present to psychiatric providers. Therefore, psychiatric nurse practitioners should have a basic understanding of celiac/gluten sensitivity to assist with early detection and diagnosis.
Gliadin, the offending protein in gluten, causes a breakdown of the protective cells of the gut. This occurs in all people, regardless of celiac status, and can lead to increased gut permeability [ii]. Essential this process allows dangerous macromolecules into the gut and eventually into the blood stream[iii]. This stimulates an inflammatory reaction that has been found to have an effect on neuronal Purkinje cells, cortical neurons and the brain stem[iv] [v]. There is evidence to suggest a gluten free diet causes a regression of the inflamatory assult as well as a lessening of psychiatric symptoms in celiac patients.
What does this mean to psychiatric practitioners? Undrstanding that there is a connection between psychiatric disorders and celiac is essential in managing our client’s overall health. A history of familial food sensitivities and GI disorders is often common in psychiatiric, gluten sensitive patients. If this connection exists testing can be helpful in making a diagnosis. If caught early the prognosis is good and the client can be managed with a combination of a gluten free diet and psychotropic medication. A full recovery from psychiatric symptoms has been noted in several studies but the diet complexity and lifstyle changes warrent a referal to a nutritionist.  
For more information or complete list of references please contact pikec@uw.edu


[v] Boscolo, S. et al. (2007) Gluten ataxia: passive transfer in a mouse model. Ann N Y          Acad Sci, 1107, 319-28.


Tests
CD/GS
Sensitivity
Specificity
Notes
tTG-IgA (TG2)
CD
95%
90%
If positive it is villous atrophy highly likely but a negative does not rule out CD or GS
IgA-AGA
GS
53-100%
65-100%
Can positive with extra-intestinal symptoms, a negative does not rule out CD/GS
IgG-AGA
GS
57-100%
42-100%
Can positive with extra-intestinal symptoms, a negative does not rule out CD/GS
False positive in Crone’s, wheat protein allergy, and with recent diarrhea
Anti-deaminated gliadin-IgA/IgG
CD
90&92%
Respectively
98&75%
Respectively
Shows CD before intestinal damage occurs

Total IgA
CD/GS
No Data
No Data
IgA deficiency can cause all AGA tests to show false negative
TG6
GS
No Data
No Data
Associated with neurological symptoms
Not readily available yet
Genetic
CD/GS
% in CD
% in GS
Notes
HLA-DQ8
CD/GS
95%
50%
30% of the general population will have this halotype, Helps with inconclusive serology
HLA-DQ2
CD/GS
5%
9%
Helps with inconclusive serology
HLA-DQ1
GS
0
1%
Helps with inconclusive serology
Biopsy results
Increased
intraepithelial
lymphocytes
Crypt
Hyperplasia
Villous
Atrophy
Notes
Marsh Grade I
Present
Not
 present
Not
Present
Found in pre-celiac and GS
Marsh II
Present
Present
Not
Present / Partial
Pre-Celiac/CD
Marsh Grade III
Present
Present
Total
Celiac Disease

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