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

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[i] Hadjivassiliou, M., R. A. (2006a) Neuropathy associated with gluten sensitivity. J Neurol Neurosurg Psychiatry, 77, 1262-6.

[ii] Drago, S., R. et al. (2006) Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scand J Gastroenterol, 41, 408-19.

[iii] Lammers, K. M. et al. (2008) Gliadin induces an increase in intestinal permeability and zonulin release by binding to the chemokine receptor CXCR3. Gastroenterology, 135, 194-204.e3.

[iv] Hadjivassiliou, M., S. et al.(2002) The humoral response in the pathogenesis of gluten ataxia. Neurology, 58, 1221-6.

[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

Baby bok choy courtesy of full circle farms!!!

Really great box of organic produce arrive at my door this week. Here is one of the meals I made.


Ingredients
Bok choy
Red and greeen pepper
Onion
crimini mushrooms
Organic grass fed sirloin tip
ginger
Tamari
Chili oil
lime
coconut oil
coconut butter




In a small bowl add ginger, tamari, lime and chili oil. Set aside.
Saute onions and bok choy stems (they cook faster than the leaves) in tons of CO. remove and place aside


Separately in a cast iron fry steak to char outside, again in CO. Remove and rest ( the steak not you).
Saute the peppers and mushrooms then add in the sauteed bok choy stems and onions and beef ontop. Then pour the sauce from in the small bowl. Give a little stir then put the bok choy leaves in and stir. Once the bok choy is glossy you are ready to serve!


side note- I like to throw a bit of coconut butter in each dish. mmmmm.

Why gluten is the equivalent of evil.

In my almost 10 years of being gluten free I have made countlessly attempts to attest to the actual east of a GF lifestyle. Although, I believe it is fairly simple, most people tend not to get past the no bread for their sandwiches part. Their blank expression screams "you lost me at no bread." The other expression I get is as if they are giving me the 5 year olds response in the heads "LALALALALA I'm not listening!" Fortunately adults have learned that the act of actually covering their ears whilst someone speaks is inappropriate. Nevertheless, I can see the desire to resort to this when I explain how gluten affects the system.


You can cover your eyes if this starts to have the previously explained effect on you.




Here it is...


Gluten is a molecule contained in wheat, rye, barley and through cross-contamination on oats. The offending protein in gluten is called gliadin. This gliadin is further dissected into several areas that all have very separate effect on the gastrointestinal tract depending on genetic expression. 


What does that mean for you? This stupid little molecule can exacerbate any inflammatory condition in the body. This is a non-discriminatory statement. Meaning you do not have to have celiac or gluten sensitivity to be affected by gluten. Gliadin, the offending protein in gluten, causes an initial insult at the intracellular tight junctions located on the luminal side of the intestine. These tight junctions are responsible for maintaining the integrity of the intestinal wall and keeping out macromolecules. Gliadin binds with CXCR3, a chemokine receptor responsible for leukocyte recruitment and eventually involvement of T-helper cells. Lammers and colleagues (2008) reported a higher concentration of CXCR3 in the gut epithelium of those with celiac disease as compared to those without.


CXCR3 recruits myD88, an adaptor protein, allowing the release of zonulin to the apical side of the epithelium (Lammers et al. 2008, Clemente et al. 2003). Zonulin, in celiac, is responsible for the changes in cellular structure and arrangement of the cytoskeleton which allows for increased gut permeability. Interestingly, in non-celiac intestinal epithelium, zonulin strengthens the tight junctions (Drago et al. 2006).  While both celiac and non-celiac tissue reacted to gliadin, only the celiac epithelial membrane up-regulated the production of the mRNA for CXCR3 gene expression at a 9.6 fold increase. When gliadin was removed, the expression of the CXCR3 in the tissues of celiac patients decreased to what was seen in those without celiac disease (Lammers et al. 2008). It is important to note that CXCR3 is expressed in several other cells including natural killer cells, and CD3⁺/CD8⁺ T cells which could account for the instigation of the innate immune response associated with celiac disease. In addition, toll like receptors, which are also responsible for innate immune response, have been reported to be increased in the duodenum of children with celiac as compared to healthy controls (Szebeni et al. 2007). 


Tight junctions in the epithelial wall are critical for maintaining the integrity of the gut. The increased permeability seen in celiac disease appears to be associated with the onset of other autoimmune disorders (Drago et al. 2006, Sapone et al. 2006, and Watts et al. 2005). Although, I would not be surprised if it was a bit more chicken and egg-ish.


Bottom line
If you are suffering from any autoimmune disorder gluten is probably one of the most detrimental pieces of the puzzle. Stop eating gluten and you can begin to heal depending on the amount of damage done. 


If you do not have an autoimmune disorder gluten is your russian roulette for one.  


Gluten causes intestinal permeability changes in celiacs and non-celiacs alike.