Underestimated Psychometabolic Aspects in Child Psychiatry

1
(No Transcript)
2
(No Transcript)
3
Underestimated Psychometabolic Aspects in
Child PsychiatryBySamir m monirlecturer of
neuropediatricsminia university
4
(Metabolism and Psyche)

• Still offering an amazing area in research

5

• Inherited and metabolic diseases two words
  send chills down the spine of a junior doctor and
  represent endless hours one spent learning all
  about mutations, enzymes, co-enzymes and
  substrate deficiencies and still failed to grasp
  the complexity of the problem.
• Dr Clarke. 2006 Cambridge
  University

6
Brain

• 1.36 kg
• Over 100 billion neurons, or signaling units.
• Controls everything we do
• If injured, it may affect basic functions,
  including thought, behavior, memory and speech
• Underappreciated organ

7

• Metabolism (from Greek, metabole, "change") can
  refer to all chemical reactions that occur in
  living organisms.
• Metabolism is usually divided into Catabolism,
  that breaks down organic matter and produces
  energy by way of cellular respiration and
  anabolism that uses energy.

8
(No Transcript)
9
Metabolic pathways
10

• We will discuss
• Historical BackgroundPsychiatric Presentation of
  Metabolic DisordersMetabolic Disorders and
  Common Neurodevelopmental Syndromes
• Diet , Nutritional Disorders and Child Psychiatry
  
• Psychopharmacologicl Aspects
• Family Aspects
• Acknowledgement

11
Historical Background

• Inherited disorders have accompanied humanity
  since its earliest existence as remarkable in
  many prehistoric and historic sites. In Egypt,
  investigation of mummies from the huge necropolis
  of Thebes-West in Upper Egypt revealed osseous
  manifestations suggestive of metabolic disorders.

12

• Pharaoh Akhenaten, might had the aromatase excess
  syndrome.

13

• The periodic madness of King George III has
  been attributed to acute intermittent porphyria
  (AIP)

14

• Van Gogh.

15

• Metabolic disorders caused by genetic mutations
  resulting in enzyme deficiencies in an
  intermediary metabolic pathway, constitute a wide
  spectrum of diseases in clinical practice. The
  term inborn errors of metabolism was introduced
  by Sir Archibald Garrod at the beginning of the
  twentieth century.

16
(No Transcript)
17

• More than 6500 inherited disorders, known to
  affect world populations. The overall incidence
  was estimated to be 1 in 1,400 live births.
  However, this rate may be an underestimation, as
  new disorders continue to be discovered because
  improvement in diagnostic techniques sensitivity
  and accuracy. Although individually rare, they
  are collectively numerous. Prevention of death or
  permanent neurological sequele is dependent on
  early diagnosis and initiation of appropriate
  therapy . Diagnosis is done by clinical
  assessment, imaging studies, electrophysiological,
  histopathological and biochemical studies).

18
Raghuveer et al 2006
19

• Psychiatric Presentation of Inborn Errors of
  Metabolism
• Neurological dysfunction is an important
  manifestation of inherited metabolic disorders.
• Over one-third of the inherited metabolic
  disorders are characterized by the central
  nervous system involvement. Neurological symptoms
  are the presenting and the most prominent
  clinical problems associated with them. Among the
  neurometabolic disorders, there are particularly
  five common neurological presentations chronic
  encephalopathy, acute encephalopathy, movement
  disorder, myopathy and psychiatric or behavioral
  abnormalities

20

• Child psychiatry, in particular, needs miracles
  to unravel all its mysteries. Inborn errors of
  metabolism (IEMs) may present in childhood,
  adolescence as well as adulthood as a phenocopy
  of a psychiatric disorder. Fortunately, many of
  these IEMs are treatable. However, diagnostic
  procedures and specific therapeutic modalities
  should be early at the 'psychiatric stage' to be
  effective. After that the occurrence of
  irreversible neurological lesions or profound
  mental delay will appear.

21

• It is important to detect metabolic disorders for
  several reasons
• (1) Specific treatments may be available
• (2) Metabolic decompensation may be avoided
• (3) Accurate counselling may be given.
• Sedel et al did a schematic classification of
  metabolic disorders into three groups according
  to the type of psychiatric signs at onset.
• Group 1 represents emergencies, in which
  disorders can present with acute and recurrent
  attacks of confusion, sometimes misdiagnosed as
  acute psychosis. Diseases in this group include
  urea cycle defects, homocysteine remethylation
  defects and porphyrias.
• Group 2 includes diseases with chronic
  psychiatric symptoms arising in adolescence or
  adulthood. Catatonia, visual hallucinations, and
  aggravation with treatments are often observed.
  This group includes homocystinurias, Wilson
  disease, adrenoleukodystrophy and some lysosomal
  disorders.
• Group 3 is characterized by mild mental
  retardation and late-onset behavioural or
  personality changes. This includes
  homocystinurias, cerebrotendinous xanthomatosis,
  nonketotic hyperglycinaemia, monoamine oxidaseA
  deficiency, succinic semialdehyde dehydrogenase
  deficiency, creatine transporter deficiency, and
  a and b mannosidosis.

22
(No Transcript)
23

• The need to screen for an inborn error of
  metabolism arises out of the fact that most cases
  take to irreversible effects as time progress.
  Emphasis has to be laid on early detection and
  prompt management,

24

• Algorithm for patients with a number of
  treatable inherited metabolic conditions.

25

• organic causes of psychosis should be considered
  among patients with atypical psychiatric symptoms
  After further diagnostic processes, easy-to-apply
  screening tests are now available that can assist
  in confirming diagnoses

26

• Treatment used in psychiatry and which may
  aggravate metabolic diseases

27
Psychiatric features of inherited metabolic
disorders by Turnacioglu et al., 2013
28

• Psychosis

29

• Psychosis
• Certain inborn errors of metabolism as
  homocysteine metabolism disorders, urea cycle
  disorders, porphyria, Wilson disease,
  cerebrotendinous xanthomatosis and Niemann-Pick
  disease type C can present as psychosis. It
  should be considered in patients with atypical
  psychiatric symptoms. Some IEMs are treatable
  especially during the early stages of disease
  (sometimes simply with vitamin replacement or
  supplementation) and new treatments continue to
  appear.
• Atypical psychiatric symptoms including acute
  onset and /or early onset, fluctuating course,
  confusion, catatonia, visual hallucinations,
  progressive cognitive decline, intellectual
  disability, treatment resistance Unusual or
  severe side effects

30

• Inborn Errors of Metabolism and Common
  Neurodevelopmental Syndromes

Spectrum of Childhood Behavioral and
Neurodevelopmental Disorders by Greenspan et
al., 1998
31

• Although each disorder is distinct, some
  clinicians do not see these conditions as
  discrete entities, but a continuum of disorders
  with related features. All share similar
  etiologies, common presentations as well as
  responsiveness to common treatment approaches.
• All share common triggers nutrient deficiencies
  fatty acid abnormalities hyper-sensitivities or
  intolerances to food adverse responses to food
  additives, preservatives, artificial colors and
  flavorings, sulfites, salicylates and phenols
  all as co-existing problems in many of these
  disorders.
• Researchers suggest that incomplete digestion of
  wheat and other gluten containing grains as well
  as milk/dairy products can be linked to
  behavioral symptoms recognized in those with
  developmental problems

32
Autism
33

• Autism
• Autism spectrum disorder (ASD) is the broad term
  includes autistic disorder, Asperger syndrome,
  and pervasive developmental disorder, not
  otherwise specified. These disorders share common
  features of impaired social relationships,
  impaired communication and language, and
  stereotypic mannerisms or a narrow range of
  interests, associated with behavioral problems,
  such as hyperactivity and aggression. Although
  it's exact cause is not known, several factors
  have been implicated in its etiology, including
  inborn errors of metabolism. Although relatively
  uncommon, it's more likely to occur in certain
  countries, such as in the Middle East, where
  recessive conditions are common because of
  consanguinity.
• The following disorders were identified
  phenylketonuria, glucose-6- phosphatase
  deficiency, propionic acidemia, adenosine
  deaminase deficiency, mitochondrial disorders,
  and branched chain ketoacid dehydrogenase kinase
  deficiency.

34

• ADHD

35

• ADHD
• ADHD occurs in approximately 46 of the
  population and is defined by developmentally
  inappropriate levels of inattention,
  hyperactivity, or impulsivity. A highly heritable
  condition thought to have its basis. ADHD is
  currently categorized into three subtypes with
  varying rates of prevalence ADHD-inattentive
  subtype, ADHD-hyperactive/impulsive subtype, and
  ADHD-combined subtype. Stimulant medications in
  conjunction with psychosocial treatments such as
  behavioral management training for parents, are
  the most efficacious treatments for ADHD

36

• Developmental Delay

37

• Developmental Delay
• Intellectual disability (developmental delay)
  affects 2.5 of population worldwide. It is a
  life-long and debilitating condition with
  deficits in cognitive functioning (IQ less than
  70) and adaptive skills, often associated with
  behavioural problems (autism, hyperactivity and
  aggression), epilepsy and other neurological
  disabilities, all resulting in psychological,
  social and economic burdens. In children less
  than 5years of age with deficits in two or more
  developmental domains (e.g. fine/gross motor
  skills, speech, interaction, etc.). The etiology
  of ID is diverse, including infectious, traumatic
  and toxic causes. Genetic etiologies constitute
  the most frequent cause and are demonstrable in
  more than 50 of individuals with ID

38
(No Transcript)
39
(No Transcript)
40
Overview of all causal therapies (n91). Van
Karnebeek and Stockler (2012)
41
(No Transcript)
42

• Diet
• There's another face of food we dont know
  enough, called behavior. Nutrition plays a direct
  role in cognition and behavior in children and
  adolescents.
• Dietary treatment of children with behavioral
  disorders has had a controversy since the 1920s.
  
• Dietary management of IEM include medical foods
  that provide the majority of nutrient needs,
  specialized for individual disorders and dietary
  supplements that are used to enhance diminished
  catalytic function, replace conditionally
  essential nutrients, or provide essential
  nutrients that may be missing due to dietary
  restrictions.
• Common Dietary Interventions Additive-free diet,
  sugar elimination diet, food allergies, fatty
  acid supplementation and gluten-free, casein-free
  diet.

43

• Obesity
• Worldwide estimates of childhood obesity are as
  high as 43 million and it continues to increase
  each year. It has been accompanied by much
  serious and severe comorbidity. The psychiatric
  aspects related to obesity in pediatric age are
  still poorly studied and the link between obesity
  and psychiatric symptoms appears to be
  unclarified.
• Many propose behavioral problems are a result of
  the stigmatization associated with childhood
  obesity, but there is also evidence supporting
  that behavioral problems may precede in some
  children.

44
(No Transcript)
45

• Malnutrition
• Early childhood malnutrition is associated with
  cognitive and behavioral impairment during
  childhood and adolescence. Malnutrition limited
  to the first year of life with good health and
  nutrition documented to 12 years of age, is
  associated with a significant overrepresentation
  of adult personality trait scores outside of the
  average range involving anxiety, depression,
  lowered interpersonal orientation, apathy and
  lowered sense of self-efficacy or competence.
• Even in mild malnutrition, subtle changes in diet
  may modulate brain function. Both vitamins and
  minerals are essential (esp, vitamin C, folic
  acid, vitamin B6, magnesium, calcium, zinc,
  niacin, niacinamide, and dimethylglycine) which
  play a valuable role in the treatment of children
  with attention deficit disorder or autism
  spectrum disorder.

46
Psychopharmacologicl Aspects
47

• Antipsychotics and Metabolism
• There is a growing evidence supporting the
  presence of metabolic, neurological and
  sexual/reproductive adverse effects in children
  treated with antipsychotics, mood stabilizers and
  selective serotonin reuptake inhibitors (SSRIs).
• Adverse effects include weight gain, obesity,
  glucose dysregulation, dyslipidaemia,
  hyperprolactinaemia and incident cardiovascular
  events as orthostatic hypotension. These side
  effects could lead to serious complications in
  children.
• This was more significant with younger ages,
  females, multiple drug use and with atypical
  antipsychotics than typical antipsychotics.
• Special considerations should be given before
  initiating treatment and clinical monitoring is
  essential. More research is needed to develop
  strategies to minimize antipsychotic-related
  adverse effects and to discover treatments with
  lower risk potential.

48
(No Transcript)
49

• Family
• Little is known about parents' perspectives on
  child development and social impact on families.
  Living with a metabolic disorder may cause
  considerable stress on patients and families
  (Gramer et al., 2014)
•  
• Parents of children diagnosed with ADHD were more
  likely to divorce and had a shorter latency to
  divorce than parents of children without ADHD.
• Mothers of children with mental disorders have
  poor quality of life, poor sleep and high
  prevalence of mental disorders hence child
  psychiatry clinics need to ensure that mothers
  receive appropriate care along with the child.

50
(No Transcript)
51
(No Transcript)
52
(No Transcript)