Nutritional Psychiatry Flashcards
What is malnutrition?
A state of nutrition in which deficiency or excess of energy, protein, and other nutrients causes adverse effects on tissue and body form, function, and clinical outcome
What are the two main routes to malnutrition?
- Insufficient or inappropriate food intake
- Normal intake but failures of digestion or metabolism
What are the two main categories of malnutrition?
- General malnutrition/calorie deficiency
- Deficiency of specific nutrients (e.g. protein)
What is kwashiorkor and what are it’s main features?
A protein deficiency, characterised by moon face, swollen legs, swollen abdomen, flakey skin, sparse hair, thin muscles but still fat present, little interest in surroundings
What is marasmus and what are it’s main features?
A calorie deficiency, characterised by very underweight body, old appearance, thin limbs with little muscles or fat
Can an individual have both kwashiorkor and marasmus?
Yes! - marasmic kwashiorkor
How does the Waterlow criteria (1972) classify malnutrition?
Height and weight compared to population norms
How does the WHO criteria (1999) classify malnutrition?
Number of SDs between observed and expected weight and height (-2 = moderate, -3 = severe)
What is chronic malnutrition?
Sustained, long-term malnutrition that is not severe enough to cause death but can lead to a variety of long-term problems, including neuropsychiatric
In acute starvation, when does the CNS usually become affected?
In the later stages
What might you see prior to coma in acute starvation?
Delirium and encephalopathy
What is the major challenge when investigating the neuropsychiatric sequelae of malnutrition?
Interpretation difficulties - most illnesses or situations that lead to malnutrition are very unpleasant so it can be difficult to tell which psychiatric effects are directly related to the malnutrition itself.
What is pyloric stenosis?
A condition where the pylorus muscles thicken, narrowing the passage between the stomach and the small bowel. This prevents food from passing through, leading to vomiting
What neuropsychiatric problems have been found to be associated with pyloric stenosis?
Short-term memory and attentional deficits
What was the Barbados Nutrition Study?
A 40 year longitudinal study following individuals with normal birth weight but a period of protein-energy malnutrition in first year of life
What did the Barbados Nutrition Study find early malnutrition was associated with in later life?
Mainly attentional deficits anf hyperactivity, but also lower IQ, increased prevalence of LD, and subtle motor deficits
What are macronutrients?
Nutrients we need in larger amounts such as proteins, fats, and carbohydrates
What are micronutrients?
Nutrients we need in small amounts such as vitamins, minerals, and trace elements
What category of vitamins is most relevant in psychiatry?
B vitamins
What is B1 and which foods are rich in it?
Thiamine - green peas, tomatoes, sunflower seeds, spinach, squash, brussel sprouts
How much thiamine is absorbed normally if taken orally?
~10%
What is thiamine (B1) deficiency associated with?
Alcohol dependency (~30% of alcoholics)
Why is thiamine deficiency associated with alcohol dependency?
Alcohol compromises the absorption and utilisation of thiamine (~1%), likely exacerbated by poor diet
What conditions, aside from alcohol dependency, have also been linked with thiamine deficiency?
Morning sickness (hyperemesis gravidarum) and malabsorption conditions that lead to protracted vomiting
What is Beriberi?
A condition caused by thiamine deficiency, characterised by weakness, lack of energy, myalgia and cardiac problems
What are of the nervous system is primarily affected in Beriberi?
The peripheral nervous system
What are the main features of ‘wet’ Beriberi?
Cardiac failure, lower limb oedema, and lactic acidosis
What are the main features of ‘dry’ Beriberi?
Neurological features such as peripheral nerve damage, sensory and motor deficits, and muscle wasting
Deficieny in which nutrient is associated with Wernicke’s Encephalopathy?
Thiamine (B1)
What is the classic triad of acute presentation Wernicke’s encephalopathy?
- Confusion
- Cerebellar ataxia
- Opthalmoplegia (eye muscle weakness)
Why might Wernicke’s encephalopathy be hard to spot?
It’s presentation resembles being very drunk and only 30-40% present with the triad
How is Wernicke’s encephalopathy treated?
High dose parenteral (IV) thiamine
Which subtype of Wernicke’s encephalopathy has the best prognosis?
non-alcoholic WE
Is Wernicke’s encephalopathy reversible?
Yes, if treated quickly enough
Is high dose IV thiamine safe if not thiamine deficient?
Yes!
What percent of alcoholic WE survivors develop Korsakoff syndrome?
85%
Which brain areas are preferentjly affected in Wernick encephalopathy?
The mammillary bodies, as well as the thalamus, brainstem, and cerebellar vermis
Which brain areas are typically unaffected by Wernicke’s encephalopathy?
The cortex
What is Korsakoff syndrome?
A chronic amnestic state caused by severe thiamine deficiency and alcoholism, typically arising from untreated Wernicke’s encephalopathy
What is the characteristic symptom of Korsakoff syndrome?
Confabulation - undeliberately generating false memories to fill in the gaps
Is Korsakoff syndrome treatable with thiamine?
No, they will likely just need long-term specialist care
What is the primary neurological finding in Korsakoff syndrome?
Atrophy of the mammillary bodies, seen in 80% of patients. The whole brain may also be atrophic
What is vitamin B3?
Niacin
What is Pellagra?
A disease caused by niacin deficiency
What are the four D’s of Pellagra?
- Dermatitis
- Diarrhoea
- Dementia (variable psychiatric symptoms)
- Death
What type of diet is associated with niacin deficiency?
A maize-based diet (caused a public health crisis in early 1900s America)
How do we prevent niacin deficiency?
Food is now routinely fortified with niacin
What foods are rich in niacin (B3)?
Poultry, meat, mushrooms, tomatoes, potatoes, liver, fish, peanuts, spinach
What is B12 associated with?
Myelin production (alongside B9/folate)
What symptoms might you get with B12 deficiency?
▪️ Loss of vibration sense
▪️ Subacute combined degeneration of spinal cord
What is subacute combined degeneration of the cord?
▪️ Thinning of spinal cord
▪️ Dorsal and lateral columns
▪️ Sensory disturbance (tingling, numbness)
▪️ Untreated = motor deficits such as spasticity, paraplegia, ataxia
Potentially reversible with B12!!
Why is there a current rise in cases of young, healthy people with subacute combined degeneration of the cord?
Nitrous oxide (NOS) inactivates B12
Where is folate concentration naturally greater?
In the CSF compared to blood due to active transport across BBB
(Important because levels may look healthy in blood test but still have cerebral folate deficiency)
How can you test for cerebral folate deficiency?
Lumbar puncture - look for low CSF 5-MTHF
NOT a nutritional deficiency - still getting enough it just isn’t reaching the brain
What are the most common features of CFD?
▪️ Pyramidal spasticity
▪️ Cerebellar movement disorders
▪️ Intellectual disability
4 distinct syndrome? - autistic, schizophrenic, spastic-ataxic, epileptic
What are the signs of vitamin C deficiency?
▪️ Poor wound healing
▪️ Severe joint and muscle pain
▪️ Dental avulsion (teeth fall out)
▪️ Oedema
▪️ Spontaneous haemorrhage
▪️ Fatigue, weakness, and parkinsonism
▪️ Scurvy! - rare in developed world, look for fatigue?
What is vitamin D deficiency associated with?
▪️ Depression
▪️ Schizophrenia
▪️ Parkinsonism
▪️ Dementia
due to hypocalcaemia?
NOTE: many people have vit D insufficiency NOT deficiency
What are the main features of calcium deficiency?
▪️ Poor development, fracture healing and brittleness of bones and teeth
▪️ Neuromuscular hyperexcitability triad (spasm, tetany, hyperreflexia)
▪️ Depression and acute confusional state
Similar to magnesium!
What are the main signs of iron deficiency?
▪️ Microcytic anaemia
▪️ Weakness, fatigue, low mood
▪️ More common than change in mood disorder and neurodevelopmental conditions?
What are the main signs of zinc deficiency?
▪️ Similar to vitamin C as act together but milder
▪️ Give zinc whilst treating vitamin C deficiency
What are the main signs of iodine deficiency?
▪️ Now seen rarely due to fortification
▪️ Largely prenatal and infant: short stature, spasticity, deaf-mutism, mental retardation, hypothyroidism
Important for normal thyroid functioning!
What are the main signs of selenium deficiency?
▪️ Anxiety
▪️ Depression
▪️ Dementia
BUT don’t need much. tied closely with iodine
How might nutrients be used for treatment in neuropsychiatry?
▪️ B vitamins for schizophrenia symptoms?
▪️ Role yet to still be discovered?
▪️ Biomarkers?
