Stock photo. Not actual patient.
A Psychiatric Presentation of Celiac Disease
Celiac disease can present with psychiatric symptoms alone, so unresponsive psychiatric cases with multi-system complaints (allergies, autoimmunity, pain, GI issues, brain fog) often warrant a celiac panel. Discover how treating the underlying nutrient deficiencies can aid in recovery.
Initial Presentation
Dolly was a 32-year-old woman presenting with a long history of mood dysregulation, anxiety, depression, brain fog, and difficulty concentrating.
A previous psychiatrist diagnosed her with major depressive disorder, generalized anxiety disorder, and ADHD. She was treated with fluoxetine, escitalopram, bupropion, and Adderall without any meaningful improvement in her symptoms. She discontinued all medications prior to her initial visit.
In childhood, she dealt with asthma, chronic urticaria, recurrent sinus infections, tonsillectomy. In her 20s, she began having widespread musculoskeletal pain and chronic diarrhea. A rheumatologist diagnosed her initially with fibromyalgia, and later after labs revealed a positive ANA and rheumatoid antibodies, she was diagnosed with mixed connective tissue disease and was started on hydroxychloroquine.
At the initial visit, she reported frequent mood swings that strained her marriage and ruined several friendships. On exam, she was emotionally labile, hyperverbal, slightly pressured, and frequently derailed off topic. In the past, when she was severely depressed, she could sleep all day and only got up to urinate. At other times, she felt unusually elevated, required very little sleep and felt like she could “conquer it all.”
Initial Treatment for Psychiatric Symptoms with Low-Dose Lithium
Her symptoms raised concern for Bipolar II Disorder. Lamotrigine was initially recommended. However, she was skeptical of a bipolar diagnosis and was reluctant to start any new psychotropic medication. She was willing, however, to start a trial of low dose nutritional lithium (lithium orotate), with the understanding that it was unlikely to offer adequate control of her symptoms given the severity of her symptoms.
Two weeks later, she returned with notable improvement in her mood after starting lithium orotate at 10mg daily. She was much less irritable and more organized in thought. However, her mood was still significantly dysregulated when dealing with minor life stressors.
Relevant Lab Tests
Routine bloodwork was obtained that included a comprehensive celiac panel. Her lab results were significant for elevated tissue transglutaminase (tTG) IgA antibody at 29, normal total IgA, elevated homocysteine at 16.8 µmol/L, and low 25-OH vitamin D at 19 ng/ml.
Diagnosis of Celiac Disease
Celiac disease was diagnosed and she was advised to eliminate gluten and dairy from her diet (dairy sensitivity commonly co-occurs in Celiac disease). She was started on vitamin D3 5000 IU daily with vitamin K2, a multivitamin that contained methylated B vitamins, and magnesium glycinate 240mg at bedtime.
At the next follow up visit, she was too emotionally overwhelmed to make any dietary changes. She was now receptive to starting lamotrigine with the hope that it would stabilize her mood enough to make progress on dietary changes. Lamotrigine was started and titrated up to 100mg with good response.
As her treatment progress, she eliminated gluten completely from her diet. She reported dramatic improvement in her mood, mental clarity, and noted complete resolution of her diarrhea and joint pain. Her new rheumatologist took her off hydroxychloroquine and told her she no longer met criteria for fibromyalgia or mixed connective tissue disease.
Follow-up Labs & Treatment
About 6 months into her treatment, she was virtually symptom free. With tears of joy, she thanked me and stating “I finally have my life back.” To her surprise, she noticed substantial improvement in her PMS symptom as well. Her marriage was stronger than ever. She got a new job and started going back to the gym.
Repeat lab testing showed normalization of homocysteine down to 8 µmol/L and a vitamin D level that was optimized at 51 ng/ml.
Given the severity of her symptoms at presentation, lack of family history of bipolarity, and dramatic improvement on a modest dose of lamotrigine, it’s suspected that at least part of her psychiatric presentation was explained by untreated Celiac disease. After a sustained period of stability, the plan is to reassess the need for lamotrigine by trying to slowly taper off.
Case Study: Celiac Disease and Mental Health
This case highlights several important lessons for clinicians:
- Celiac disease can present primarily with neuropsychiatric symptoms, even in the absence of gastrointestinal symptoms.
- A history of allergies, autoimmunity, chronic musculoskeletal pain, gastrointestinal symptoms, and/or brain fog should raise suspicion for Celiac disease.
- Lack of response to multiple psychotropic medications and the presence of multi-system symptoms should raise suspicion for an inflammatory disease process.
- A comprehensive celiac panel should be routinely ordered as part of the initial work up of the psychiatric patient, even in the absence of GI symptoms. The test is easily accessible and covered by most insurance plans.
- Addressing nutrient deficiencies secondary to intestinal malabsorption with supplementation can aid in recovery.
