Celiac Disease and Psychological Problems

A recent study (A Butwicka et al. J Pediatr 2017; 184: 87-93) describes an increased rate of childhood psychiatric disorders among children with celiac disease (CD).

The authors used a nationwide registry (in Sweden) with 10,903 children with celiac disease, 12,710 siblings, and more than 1 million control patients. The median age at diagnosis was 3 years and median duration of followup was 9.6 years.

Key findings:

  • CD patients had a 1.4 fold greater risk of psychiatric disorders, including mood disorders, eating disorders, behavioral disorders, and ADHD.
  • CD siblings did not have an increased risk.
  • 7.7% of children with CD were diagnosed with a psychiatric disorder

Limitation: The actual reported incidence of psychiatric disorders seems low in both the CD patients and controls.  It is possible that some of the difference could be related to selection bias. Patients with (undiagnosed) psychiatric disorders may be more likely to be anxious, and seek out medical attention for their GI complaints;  this could precede a diagnosis of CD.

Strengths: This study has large numbers of patients and the data was prospectively obtained.

The association with increased psychiatric problems could have a biologic basis or be related to the toll of chronic gastrointestinal symptoms prior to diagnosis and the difficulty of managing CD.

My take: This is an intriguing study and suggests that patients with CD are more likely to be diagnosed with a psychological disorder.  Whether CD itself or the preceding symptoms trigger this diagnosis is uncertain.

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Celiac Diseaase and Diabetes

A recent review (B Weiss, O Pinahs-Hamiel. JPGN 2017; 64: 175-79) of the medical literature describes the various recommendations regarding celiac disease (CD) and type 1 diabetes mellitus (T1DM).

Key points:

  • Two-thirds of patients with T1DM and CD are asymptomatic for CD at diagnosis
  • Many children with T1DM and with positive CD serology may normalize the serology spontaneously.   In one study with 446 children with T1DM who were screened for CD, 38 had persistently abnormal serology whereas 27 had fluctuations in CD serology.  In another study with 738 children, of 48 patients with positive CD serology, normalization was evident in 35% at 1 year.

The authors review recommendations for CD screening.  Several guidelines have recommended soon after diagnosis (especially if >2 years of age).

screenshot-149

Their figure 1 algorithm provides guidance on evaluation.  In those patients with T1DM and positive CD serology, if they are asymptomatic, assuring that serology is persistently elevated may be worthwhile before proceeding with small bowel biopsy.  In those who initially test negative for serology, there may be a role for HLA testing and/or periodic screening every few years.

Related editorial on recent article: Celiac Disease, Gut-Brain Axis, and Behavior: Cause, Consequence or Merely Epiphenomenon (A Fasano)  Thanks to KT Park for this reference.  Excerpt:

By assessing the psychological functioning of infants enrolled in the Environmental Determinant of Diabetes in the Young trial and followed prospectively, the authors reported that 3.5-year-old children affected by celiac disease autoimmunity (CDA), defined as positive serology in children at risk, have increased reports of depression/anxiety, aggressive behavior, and sleep disturbances. Interestingly, these symptoms were significantly greater in the 66 children with CDA whose mothers were unaware of the diagnosis compared with the 440 children with CDA whose mothers were aware of the diagnosis and the 3651 children without CDA, decreasing the chance that the reported behaviors were biased by families’ subjective assessment…Prospective studies such as that reported by Smith et al may be a key approach to shedding light on how intestinal factors can influence human behavior and to identifying possible targets to ameliorate psychological symptoms caused by inappropriate gut-brain cross-talk.

Reference articleSmith L, et al.. Psychological manifestation of celiac disease autoimmunity in young children. Pediatrics. 2017;139(3):e20162848

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Advice on Abdominal Pain for Everyone Who Cares for Children

A recent editorial (MK Farrell. J Pediatr 2016; 177: 16-17) provides many useful pointers from a master clinician along with commentary on an epidemiology study of recurrent abdominal pain (ML Lewis et al. J Pediatr 2016; 177: 39-43).

The main finding of the study which used an internet survey of mothers (children 4-18) was that 23% of US children met the Rome III criteria for a functional GI disorder.  Constipation was the most common.

Key points in commentary:

  • John Apley’s monograph The Child with Abdominal Pains “should be read by all who care for children.”
  • Worldwide prevalence of functional GI disorders has been estimated to be 13%. Peak ages were 4-6 years and early adolescence with a greater prevalence in females
  • “A variety of phamacologic and nonpharmacologic treatments have been proposed, but none have been consistently effective except perhaps cognitive behavioral therapy and hypnotherapy.”
  • “Negative studies are not reassuring” [to families]

Pithy observations from Apley:

  • “The more time the doctor spends on the history, the less time he is likely to spend on treatment.”
  • “Doctors who treat the symptoms tend to file a prescription. Doctors who treat the patient are more likely to offer guidance.”
  • “It is a fallacy that a physical symptoms always has a physical cause and needs a physical treatment.”
  • “Anxiety like courage is contagious.”

My take: Dr. Farrell urges more research focus on interventions (diet, behavioral, alternative therapies, medical treatments) to improve outcomes and less focus on epidemiology.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

The Lawn, University of Virginia

The Lawn, University of Virginia

 

Psychological Therapies for Irritable Bowel Syndrome

A recent meta-analysis (KT Laird et al. Clin Gastroenterol Hepatol 2016; 14: 937-47) of 41 randomized, controlled trials shows that psychological therapies improved symptoms of irritable bowel in adults.

Key finding:

  • “On average, individuals who received psychotherapy had a greater reduction in GI symptoms after treatment than 75% of individuals assigned to a control condition…This effect remained significant” for at least 6-12 months.

A summary of this study from GIHepNews.com:  Psychological Therapies for Irritable Bowel Syndrome

Excerpt of commentary by Dr. Christopher Almario:

While these findings are impressive and continue to support the use of psychotherapy in IBS, important issues remain. First, these results are based on data gathered in the highly controlled environment of randomized controlled trials (RCTs), and it is unclear whether they will translate to the “real world.” RCT participants may be more willing to complete psychotherapy because they know they are being observed by research staff (referred to as the Hawthorne, or observer, effect). However, in real clinical practice, patients with IBS not subject to the Hawthorne effect may be less compliant with such therapies.

Other issues relate to the current limited adoption of psychotherapy in clinical practice. Factors contributing to the low uptake include variable third-party reimbursement and poor patient and provider acceptance (JAMA. 2015 Mar;313:949-58). Another factor is limited access to qualified psychotherapists.

My take: I often refer patients to a “pain psychologist” who works in our office.  With the right psychologist, this can be very helpful.  In addition, I feel that families are more willing to see a psychologist than in the past.

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Picky Eating and Underlying Psychological Problems

Several news outlets have summarized a recent study which showed increased risk of psychological problems associated with being a picky eater.

An excerpt of a summary is from NBC news:

Picky eating, even at moderate levels, is linked with psychiatric problems, including anxiety and symptoms of depression in kids, according to a study published Monday in the journal Pediatrics. It found the mental problems worsened as the picky eating became more severe.

“We need to do a better job of giving advice to these parents,” Nancy Zucker, study co-author and associate professor of psychology at Duke University, told NBC News.

“The first take-home message is that you’re not to blame. The second take-home message is that it’s more complicated than we think.”

The study screened more than 1,000 children ages 2 to 5, and found 20 percent were picky eaters. The researchers stress this goes beyond kids who just hate broccoli or have certain dislikes.

More than 17 percent of kids were classified as moderate picky eaters: These children had a very limited range of foods they would eat and they would not try anything else, Zucker said.

About 3 percent were considered severe picky eaters: Their sensitivities to smell or taste were so strong that even eating outside of the home was difficult. As they get older, it could be hard for them to go out with friends or eat at school. …

The researchers also note the term “picky eating” may now be obsolete. They suggest the condition might be better described as avoidant/restrictive food intake disorder (ARFID).

Also from NPR: When a Child’s Picky Eating Becomes More Than a Nuissance

 

The Connection Between Anxiety and Gastroesophageal Reflux Disease

Why is it that reflux is so much worse during periods of anxiety and depression?

A recent prospective study (Kessing BF et al. Clin Gastroenterol Hepatol 2015; 13: 1089-1095) of 225 consecutive patients with symptoms of gastroesophageal reflux disease (GERD) looks into this issue.  All patients underwent ambulatory 24-hour pH-impedance (pH-MII) monitoring and had assessment of anxiety/depression with the Hospital Anxiety and Depression Scale.

GERD was defined by having pathologic acid exposure time and/or positive temporal correlation between the occurrence of symptoms ad reflux episodes. Hypersensitivity to reflux was considered if there was physiologic acid exposure times while having temporal association between reflux episodes and symptoms.  Functional heartburn indicated the presence of symptoms with a normal pH-MII.

Key findings:

  • 147 patients had GERD and 78 had functional heartburn; 36 patients were considered hypersensitive to gastroesophageal reflux.
  • Among patients with GERD (including patients with hypersensitivity), increased anxiety/depression levels were associated with more severe retrosternal pain/burning. However, anxiety/depression were NOT associated with an increased number of reflux episodes or number of symptoms reported on pH-MII.
  • Patients with functional heartburn had higher levels of anxiety than patients with GERD.

Bottomline: Anxiety is associated with increased GERD symptoms.  In addition, anxiety is more prevalent in patients with functional heartburn.

Briefly noted: Review (Lipa S, et al. Clin Gastroenterol Hepatol 2015; 13: 1058-67) of 4 trials with 153 analyzed patients:  “Stretta [radiofrequency ablation] for patient with GERD does not produce significant changes, compared with sham therapy, in physiologic parameters, including time spent at pH less than 4, LESP, ability to stop PPIs, or HRQOL.”.

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10 Years of Anxiety and Upper Endoscopy Correlation

A recent 10-year Swedish study (Aro P, et al. Gastroenterol 2015; 148: 928-37) provided further evidence of a link between anxiety, but not depression, and functional dyspepsia (FD).

This study took a group of 1000 individuals who had been randomly selected to undergo upper endoscopy, the Abdominal Symptom Questionnaire, and the Hospital Anxiety and Depression Scale Questionnaire (1998-2001).  Among the 887, who completed the initial portion of the study, 703 subjects were available for followup study in 2010.

FD was defined in this study based on the Rome III definition: weekly bothersome postprandial fullness or early satiety; epigastric pain or burning without organic findings on endoscopy.  FD was further divided into postprandial distress syndrome which consisted of postprandial fullness or early satiety or epigastric pain syndrome.

Key findings:

  • At baseline, 15.6% of subjects had FD.  At followup, 13.3% had FD including 48 new cases.
  • Anxiety at baseline was associated with new-onset FD at the followup evaluation with an odds ratio of 7.6.
  • Anxiety was also associated with postprandial distress syndrome at baseline with an odds ratio of 4.83.

Take-home point: Anxiety often precedes functional dyspepsia.  This association was not evident with depression.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

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