CENTER ON BEHAVIORAL MEDICINE
ADDITIONAL MATERIALDIAGNOSTIC TESTING
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Medical Tests to Rule Out Physiological Causation of Psychological Presentation
Mary Ellen Langston
The interdependence of psychopathology and medical pathology is guaranteed by the interconnected, interactive nature of the human body with its physical, mental, emotional, spiritual, and social well-being intricately connected through complex mechanisms. Solomon and Moos (1964) proposed an integrative theory regarding stress, emotions, immune dysfunction, and physical disease in their landmark paper. Mohr (2003) asserts that psychological and biological factors play a dual role in mental illness and proposes that the distinction between psychological and biological disorders be discarded. Complex relationships between heredity, environment, neuroplasticity, and human behavior work conjointly in both physical and psychological dysfunction. An individual’s health is an integrated state of being which includes physical, emotional, and social well-being (Tamm, 1993).
In a literature review of stress, emotion, and immune function, O'Leary (1990) discusses evidence of the direct association between illness/disease and psychological processes. Bidirectional influences exist among negative affect, depressed immune function, stress (acute and chronic), and involved physiological processes (e.g., leukocytes, sympathetic adrenal-medullary (SAM) system, hypothalamic-pituitary-adrenocortical (HPAC) system, endogenous opioids, catecholamines, corticosteroids), personality variables, and coping styles. Neuronal activity, neurochemicals, hormones, peptides, endorphins, enkephalins, and cytokines affect the bidirectional communication between brain, body, and immune system. Involved systems include the (a) nervous system, including the brain with its repository of memories, beliefs, and attributions; (b) neurochemical system (e.g., neurotransmitters, neuropeptides, hormones); (c) hormonal/endocrine system (primarily corticosteroids); (d) immune systems, including stress mechanisms; (e) nutrition and normal body chemistry, including nutritional and neurochemical deficiencies and imbalances; and (f) feedback loops between body tissue, cells, organs (e.g., cytokines, enkephalins) (Health Education Associates, 1996). Of significant importance in this discussion is the role of psychological stressors in immune modulation. Studies support the influence of proinflammatory cytokines in promotion of physical disease (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002). Reciprocally, proinflammatory cytokine production is both initiated and sustained by stress and negative emotion and initiated and sustained by ongoing physiological disease and dysfunction.
The stress cascade is of particular importance because of its involvement in illness and disease states. The hypothalamus, pituitary gland, adrenal glands, thyroid, thymus, and reproductive glands are stress organs with hormonal feedback systems and sympathetic and parasympathetic involvement. Primary stress hormones are epinephrine and cortisol, and these are responsible for the primary stress response, with epinephrine turning on the inflammatory, defensive, and immune systems, and cortisol stimulating the anti-inflammatory mechanism. Epinephrine and cortisol affect sugar metabolism, blood clotting mechanisms, blood pressure control mechanisms, cholesterol, renal function, blood flow to digestive systems and muscles, and cardiovascular function (Health Education Associates, 1996). Stress pathways involve many areas of the brain in feedback loops, and chronic stress perpetuates a vicious cycle resulting in dopamine depletion, norepinephrine depletion, serotonin depletion, and hippocampal shrinkage (Sapolsky, 2003). When significant stress occurs in a young child’s life, the physiological stress processes that are initiated at that time may impact the individual for the remainder of his life.
Research supports the premise of pathogenic pathways in which stress promotes immunological dysfunction with stress/threat raising adrenal cortical steroids, depressing lymphocytes and antibody function, and sustaining stress. Both anxious and depressive affect are correlated to changes in physiological function, immune system function, and disease states (e.g., heart disease, allergies and asthma, cancers, ulcers, infectious diseases).
Appropriate medical intervention mediates psychological disorders, and appropriate psychological intervention promotes physical healing. To ignore potential medical conditions during psychological assessment is to ignore potential causation. Physiological dysfunction and disease states initiate, exacerbate, and sustain emotional and immune system dysregulation. Emotion dysregulation initiates, exacerbates, and sustains physical dysfunction and disease states. Immune system dysregulation initiates, exacerbates, and sustains physical disease states and emotional dysfunction.
Because physical diseases can cause symptoms associated with psychological disorders, it is imperative that evaluative testing rule out physical causation early in treatment. Because of the reciprocal nature of the body and mind, disease and mental disorder will affect, induce, and exacerbate one another. When patients have a preexisting mental diagnosis, psychological symptoms can worsen during the course of illness, both because of neurochemical changes and psychosomatic response. Another confounding problem with preexisting mental disorders is that those conditions may affect the patient’s willingness to seek treatment for physical symptoms. Mental health professionals need to work with medical professionals in responding most effectively to patient needs. Studies have shown that nearly two of five patients being treated in mental health agencies also had physical diseases and that these co-occurring illnesses were usually not detected in the mental health system. Other findings demonstrate the interconnectedness of physical and mental illness with many of the physical diseases either causing or aggravating the mental disorders (Koran, 1991).
Whenever possible, routine screening for physical diseases should occur in all hospital, inpatient, and outpatient mental health settings. This is important because (a) serious physical diseases can put the patient at risk, (b) physical disease can mimic mental disorders, (c) physical disease can worsen mental disorders, (d) physical disease can negatively affect use of psychotropic medication, and (e) failure to provide adequate assessment of physical diseases poses a legal liability to the program or agency.
Koran (1991) describes the screening of mental health patients using the methods utilized in the California Medical Evaluation Study authorized by Senate Bill (SB) 929. A complete medical evaluation is recommended and tests, procedures, and test instruments are included in the Field Manual. Tests included in the SB 929 include a (a) complete blood count; (b) 23-item chemistry panel which includes tests for glucose, albumin, serum urea nitrogen, creatinine, calcium, phosphate, alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase, bilirubin, iron, and electrolytes; (c) serum fluorescent treponemal antibody test; thyroid tests which include a triiodothyronine resin uptake, total serum thyroxine, and free-thyroxine index; (d) serum folate and vitamin B12 levels; and (e) dipstick urinalysis (Koran, 1991, p. 6). In order to complete the screening algorithm recommended by SB 929, medical history, blood pressure, and laboratory testing is required. The battery of tests can be performed by either a nurse practitioner or physician’s assistant or by referral to an external laboratory. The blood (n=13) and urine (n=3) tests maximize the potential of ruling out physical diseases when determining mental health diagnoses. Recommended tests include a hematocrit, white blood cell count, serum aspartate aminotransferase, serum alanine aminotransferase, serum albumin, serum calcium, serum sodium and potassium, serum cholesterol and triglycerides, serum T4 and free T4, and serum Vitamin B12 (Koran, 1991, p. 8-9).
Essential Blood Tests
Test explanation. The Hct measures the percentage of red blood cells (RBCs) in the blood sample and is routine in a complete blood cell (CBC) count. Blood is collected by skin puncture, measured in a capillary tube, and spun in a microcentrifuge. The Hct is the percentage of RBCs compared to total blood.
Normal range for test. Normal findings for a male are 42%-52%. Normal findings for a female are 37%-47%, and for a pregnant female, less than 33%. Values in the elderly may be less. The range for children varies according to age with newborn’s having the highest value, 44%-64%; 2-8 weeks, 39%-59%; 2-6 months, 35%-50%; 6-12 months, 29%-43%; 1-6 years, 30%-40%; and 6-18 years, 32%-44% (Pagana & Pagana, 2002, p.272-273).
Meaning of values above and below the range. Critical values are below 15% and above 60%. Increased levels of RBCs may denote the presence of the following physical diseases: erythrocytosis resulting from illness, congenital heart disease, polycythemia vera, severe dehydration, and severe chronic obstructive pulmonary disease. Decreased levels of RBCs may denote the presence of anemia, hemoglobinopathy, cirrhosis, hemolytic anemia, hemorrhage, dietary deficiency, bone marrow failure, prosthetic valves, renal disease, normal pregnancy, rheumatoid/collagen vascular disease (e.g., arthritis, lupus), lymphoma, multiple myeloma, leukemia, and Hodgkin’s disease. Chronic illnesses usually result in reduced levels of RBCs and decreased Hct (Pagana & Pagana, 2002, p.275-276).
Psychological difficulties associated with this test. RBC count denotes the presence of physical diseases such as congenital heart disease, cirrhosis, renal disease, and cancer. All of these diseases alter normal neurochemical transmissions in the brain and cause symptoms of psychological disorders. Depression is present in a significant percentage of patients experiencing physical diseases such as cancer, heart disease, diabetes, and Parkinson’s. In the bidirectional process of physical and psychological disorders, depression may either be initiator or effect of the physical disease.
As dietary deficiencies may be indicated by results of the RBC count, further evaluation may be necessary. Existing nutritional literature promotes understanding of the relationships between dietary factors (e.g., vitamins, minerals, toxicity) and mental and behavioral illnesses. Nutrition influences mental illnesses such as aggressive behavior, alcoholism, eating disorders, anxiety, attention-deficit hyperactive disorder, autism, bipolar disorder, chronic fatigue syndrome, dementia, depression, obsessive compulsive disorder, and schizophrenia (Werbach, 1999).
Cautions necessary in interpreting test results. Interfering factors can confound test results. Abnormal RBC size alters the values associated with Hct levels because the total blood cell percentage is altered. Elevations in white blood count (WBC) cause a decrease in RBC which might indicate anemia otherwise. Women while pregnant have decreased RBC. Individuals living at high altitudes have decreased oxygen availability resulting in increased Hct. Following a hemorrhage values are unreliable. Some drugs also decrease RBC (e.g., chloramphenicol and penicillin) (Pagana & Pagana, 2002, p.274).
White Blood Cell Count (WBC) and Differential Count
Test explanation. Routine laboratory testing includes the differential WBC and helps in diagnosing patients with infections, allergies, or suppression of the immune system. Leukocytosis is an increased total WBC count of greater than 10,000 and usually indicates infection, inflammation, or tissue damage or death. The WBC measures (a) total number of white blood cells or leukocytes in 1 mm3 of the blood sample and (b) the percentage of each type of leukocyte in the blood sample. WBCs are present to fight infection. When one type of leukocyte is increased, another is decreased. The WBC count measures neutrophils, lymphocytes, monocytes, eosinophils, and basophils with 75%-90% of total leukocytes composed of neutrophils and lymphocytes. Neutrophil production is triggered by infection and trauma, and neutrophils function as phagocytes. Basophils or mast cells are involved in allergic reactions and the cytoplasm contains heparin, histamine, and serotonin. These cells cause an inflammatory reaction. Lymphocytes fight chronic infections and are divided into two types: (a) T cells, which mature in the thymus and are involved in cellular immune reactions; and (b) B cells, which mature in bone marrow and are involved in antibody production. T cells are of three types: (a) killer (NK) cells, (b) suppressor cells, and (c) helper cells (i.e., T4). Differential counts add T and B cell combinations (Pagana & Pagana, 2002, p. 478-480).
Psychological difficulties associated with this test. The WBC count measures T cells and determines levels of NK cells. It is these cells which recognize and eliminate infection from the body. However, NK cells are suppressed by stress, depression, and other negative emotions. The reciprocal nature of mind and body is evident in this interaction between disease state, NK cells, and negative emotion. An individual’s health is an integrated state of being which includes physical, emotional, and social well-being, implying that emotion dysregulation impairs physical health (Tamm, 1993). Physical health affects emotion, and emotional state (i.e., neurochemical, hormonal balance) affects immune system function, which in turn affects the body’s ability to prevent infection and disease. The mind-body and body-mind links are woven into all emotional responses. With the bidirectional communication system inherent in the immune system, the mind interprets an event, the body responds with immediacy as the brain communicates to the immune system via neurochemistry, and the immune system responds by either raising or reducing immune system function.
The immune system’s
by stress, anger, anxiety, depression, and other negative emotion
Clinical depression is related to the inflammatory response which
with acute stress. Monocytes, neutrophils, and C-reactive protein are
and interleukin-6 and tumor necrosis factor-? increased
acute stress. WBC count is influenced by hormones (e.g.,
WBC counts determine the presence of allergies, and these are known to affect all systems of the body including the brain, joints, muscles, glands, lungs, kidneys, and nervous system and have been linked to over 100 medical conditions (Braley, 2006). Food allergies upset hormone and other brain chemical levels and can result in symptoms of depression, schizophrenia, and other psychological disorders.
Other indications of disease states uncovered through WBC testing which have an effect on psychological function include stress and trauma. Acute or chronic stress and trauma create a cascade of organic, hormonal, and neurochemical changes which either initiate or exacerbate existing physiology. Biological stress initiates patterns of psychological response (e.g., anxiety, depression), and psychological stress initiates patterns of biological response. The presence of nutritional deficiencies as indicated through WBC count may be manifested through symptoms of mental disorders such as depression, anxiety, and schizophrenia.
In discussing depression and mood disorders, Genova Diagnostics (2005) states that depression is intertwined with many conditions and illnesses, including amino acids, thyroid function, allergy, melatonin, adrenal hormones, digestive function, toxins, glucose, fatty acids, and female hormones. Thyroid hormone deficiency can mimic many medical and psychological conditions including fatigue, depression, headaches, premenstrual syndrome, anxiety, panic attacks, deficits in memory and concentration, muscle and joint pain, and sex drive.
Normal range for test. For
and children older than two years, normal findings for total WBCs will
be 5000-10,000/mm3 or 5-10 X 109/L (SI units). Children under two years
will normally have WBCs of 6200-17,000/mm3, and newborns will have
Critical values for total WBCs are below 2500 and above 30,000/mm3.
findings for the differential count are neutrophils, 55%-70% or
mm3; lymphocytes, 20%-40% or 1000-4000/ mm3; monocytes, 2%-8% or
mm3; eosinophils, 1%-4% or 50-500/ mm3; and basophils, .5%-1.0% or
mm3 (Pagana & Pagana, 2002, p. 477).
Meaning of values above and below the range. An increased WBC count indicates the body’s response to infection as it initiates its defense mechanism, leukemic neoplasia or myeloproliferative disorders, cancers, trauma, stress, hemorrhage, tissue necrosis, inflammation, dehydration, thyroid storm, and steroid use. A decreased WBC count may indicate drug toxicity, bone marrow failure, devastating infection, dietary deficiency, congenital marrow aplasia, myelofibrosis, autoimmune disease, and hypersplenism (Pagana & Pagana, 2002, p. 482).
Cautions necessary in interpreting test results. Newborns and infants may have high WBC count in normal conditions. Women who are pregnant and in their final month or in labor will have elevated WBC count. The elderly may not demonstrate an elevated WBC count even when infection is present. Stress, physical activity, and ingestion of food can alter values of WBC count. Other confounding factors include (a) post splenectomy patients (increased WBC levels), (b) time of day (lower in morning), (c) pharmacology (drugs increasing WBC: adrenaline, allopurinol, aspirin, chloroform, epinephrine, heparin, quinine, steroids, and triamterene; drugs decreasing WBC: antibiotics, anticonvulsants, antihistamines, antimetabolites, antithyroid, arsenic, barbiturates, chemotherapy, diuretics, and sulfonamides) (Pagana & Pagana, 2002, p. 481).
Serum Aspartate Aminotransferase (AST)
Test explanation. Evaluation of AST levels can determine coronary artery occlusive disease, liver disease, pancreatitis, renal disease, musculoskeletal disease, and trauma. The enzyme is found in metabolic tissue such as heart, liver, skeleton, kidneys, pancreas, and red blood cells, and when disease occurs, the cells lyse (i.e., cell destruction), AST is released to the blood, and the serum level rises. The amount of AST in the blood is correlated to the number of cells damaged by injury and disease and to the amount of time since the injury (Pagana & Pagana, 2002, p. 120-121). AST levels are also increased in the presence of hypothyroidism (Oxbridge Solutions, 2005).
Psychological difficulties associated with this test. Hypothyroidism, which may be indicated by the AST test, can have profound impact on psychological state, mimicking several disorders. Thyroid dysregulation may also be caused by nutritional deficiency and heavy metal exposure, and further testing is recommended. The AST may signal a trauma response which will promote complex bidirectional systemic interactions that will deplete significant neurochemicals and initiate or aggravate anxiety and depression. Chronic or acute physical conditions (e.g., heart disease, diabetes, hepatitis), which are indicated by testing, promote physiological and psychological processes either imitating, sustaining, or exacerbating psychological disorders. Glucose abnormalities present with diabetes can contribute to such psychological disorders as aggression, anxiety, attention-deficit hyperactivity disorder (ADHD), and depression (Werbach, 1999).
Normal range for test. Normal findings for the AST are 35-140 U/L for infants age 0-5 days, 15-60 U/L for children less than 3 years old, 15-50 U/L for children 3-6 years old, 10-50 U/L for children 6-12 years old, and 0-40 U/L for adolescents 12-18 years old. For adults the range for normal value is 1-35 U/L and slightly higher for the elderly (Pagana & Pagana, 2002, p. 120).
Meaning of values above and below the range. Increased levels of AST may signal the presence of heart (e.g., myocardial infarction), liver (e.g., hepatitis, cirrhosis, drug-induced liver hepatic metastasis or necrosis, infectious mononucleosis with hepatitis, or a tumor), skeletal (e.g., skeletal trauma or multiple traumas, progressive muscular dystrophy, and primary muscle diseases such as myopathy or myositis), and other disease states which cause cell injury and death (e.g., anemia, pancreatitis). Decreased levels of AST may signal the presence of renal disease, beriberi, diabetic ketoacidosis, or pregnancy (Pagana & Pagana, 2002, p. 122-123).
Cautions necessary in interpreting test results. Some factors interfere with test results. Pregnancy decreases AST levels. Exercise may increase levels of AST. Some drugs increase AST levels such as antihypertensives, cholinergic agents, anticoagulants, digitalis, erythromycin, contraceptives, and opiates. Levels appear decreased when patients have beriberi, chronic liver disease, uremia, and diabetic ketoacidosis (Pagana & Pagana, 2002, p. 121).
Serum Alanine Aminotransferase (ALT)
Test explanation. ALT is a hepatocellular enzyme that is primarily found in the liver. Liver injury or disease causes an increase in the blood, signaling liver dysfunction.
Psychological difficulties associated with this test. Since the ALT signals the presence of liver disease and may also indicate cardiovascular dysfunction or infectious mononucleosis, psychological processes will also be present. Alterations in the individual’s emotional and mental state are caused principally by the interactivity between any disease state and psychological well-being. The presence of liver disease may also denote alcoholism, and additional evaluation for alcohol and illicit drug use is recommended.
Normal range for test. Normal findings of ALT in children and adults are 4-36 IU/L at 37° C or 4-36 U/L (SI units). Levels in the men, African-Americans, and the elderly may be higher than normal. Infants may have levels that are twice that of adults (Pagana & Pagana, 2002, p. 40).
Meaning of values above and below the range. In viral hepatitis the ration between ALT and AST (DeRitis ratio) is greater than 1. In hepatocellular disease (other than viral hepatitis) the ratio is less than 1. Significant increases in ALT signal the possible presence of hepatitis, hepatic necrosis, or hepatic ischemia. Moderate ALT increases signal the possibility of cirrhosis, cholestasis, hepatic tumor, use of hepatotoxic drugs, jaundice, burns, or muscle trauma. Mild increases in ALT signal the possibility of myositis, pancreatitis, myocardial infarction, infectious mononucleosis, or shock (Pagana & Pagana, 2002, p. 41).
Cautions necessary in interpreting test results. Some variables that elevate ALT levels and confound test results include a previous injection for infectious mononucleosis or drugs recently taken by the patient. Medications interfering with results include (but are not limited to) acetaminophen, allopurinol, aminosalicylic acid, ampicillin, carbamazepine, codeine, contraceptives, oxacillin, phenothiazines, propranolol, quinidine, salicylates, tetracyclines, and verapamil (Pagana & Pagana, 2002, p. 40).
Test explanation. Tests of protein electrophoresis will include a serum albumin level. Evaluating serum proteins are useful in diagnosing cancer, intestinal and renal disease, immune disorders, liver disease, nutrition deficiencies, and chronic edema. Albumin is formed in the liver and can be measured to determine hepatic function. It composes 60% of total serum protein and transports drugs, hormones, and enzymes in the blood. Albumin levels decrease when disease affects the liver because the liver loses its ability to synthesize albumin. Albumin is also a measure of nutrition (Pagana & Pagana, 2002, p. 390-393).
Psychological difficulties associated with this test. As albumin is an evaluation of liver function having a direct effect on hormonal and enzyme activity in the body, its relationship to co-occurring psychological states is pronounced. Albumin’s primary role is to transport small molecules such as calcium through the body; therefore, its function directly affects the functions and levels of those molecules. About half of calcium is protein-bound, usually with albumin, so if albumin levels are low, usually calcium levels are low, and this is a positive indicator of malnourishment. Albumin levels are also used to diagnose kidney and gastrointestinal disorders (HealthCentersOnline, 2006). Malnutrition, because of its complex association with other body processes, could promote alternative diagnoses of such psychological disorders as anxiety, depression, schizophrenia, bipolar disorder, and ADHD. Liver, kidney, and gastrointestinal disorders would upset the body’s intricate balance of enzymes, hormones, neuropeptides, and neuromodulators, contributing to dysfunction within systems, providing potential for misdiagnosis as psychological disorders. Nutritional deficiencies are correlated with such psychological disorders (e.g., aggression, eating disorders, anxiety, ADHD, bipolar disorder, dementia, depression, obsessive compulsive disorder, schizophrenia) (Werbach, 1999).
Normal range for test. Normal findings for albumin are 3.5-5 g/dl or 35-50 g/L (SI units) in adults and the elderly. Levels in children vary according to age. Premature infants have levels of 3-4.2 g/dl; newborns have levels of 3.5-5.4 g/dl; infants have levels of 4.4-5.4 g/dl; and children have levels of 4.5-5.9 g/dl (Pagana & Pagana, 2002, p. 389).
Meaning of values above and below the range. Increased levels of albumin may indicate dehydration. Decreased albumin levels may indicate malnutrition because of lack of amino acids available for protein production. Pregnancy results in progressively lower levels of albumin. The presence of liver disease such as hepatitis, metastatic tumor, cirrhosis, or hepatocellular necrosis is demonstrated by decreased albumin levels. Malabsorption syndromes such as Crohn’s disease, sprue, and Whipple’s disease may be indicated by decreased levels of albumin because of protein loss due to inadequate absorption through the intestines. Nephropathies causing loss of protein result in significant loss of albumin through the kidneys. Other health conditions indicated by decreased levels of albumin include third-space losses (e.g., third-degree burns); overhydration, collagen-vascular diseases (e.g., lupus), inflammatory diseases, and familial idiopathic dysproteinemia (Pagana & Pagana, 2002, p.393-394).
Cautions necessary in interpreting test results. Some drugs interfere with test results and may include aspirin, bicarbonates, chlorpromazine, corticosteroids, isoniazid, neomycin, phenacemide, salicylates, and sulfonamides, tolbutamide (Pagana & Pagana, 2002, p.393).
Serum Calcium (CA)
Test explanation. Serum calcium is necessary for muscle and cardiac function, neurotransmission, and blood clotting. Testing serum calcium levels assists in the determination of parathyroid function and calcium metabolism. The test measures the total amount of calcium in the blood. When calcium blood levels decrease, parathyroid hormone (PTH) is released, resulting in the release of calcium to the blood. About half of calcium is protein-bound, usually with albumin, so if albumin levels are low, usually calcium levels are low, and this is a positive indicator of malnourishment. Serum albumin and serum calcium should both be measured, and total calcium generally decreased about .8 mg with every 1-g loss of albumin (Pagana & Pagana, 2002, p.147-148).
Psychological difficulties associated with this test. Calcium is a necessary constituent for muscle function, cardiac function, and neurotransmission. Calcium deficiency results in decreases in neurotransmitter and other chemical levels (e.g., serotonin, dopamine, epinephrine, corticotrophin-releasing hormone (CRH), glucocorticoid, norepinephrine) which are involved in the maintenance of emotional homeostasis. These deficiencies may result in symptoms resembling psychological disorders and also depress the body’s immune function. Calcium deficiency is implicated in such psychological disorders as alcoholism, anxiety, ADHD, bipolar disorder, and depression. Elevations in calcium levels have sometimes been observed in studies involving aggression, dementia, and depression (Werbach, 1999). Evidence of malnutrition implicates the range of psychological disorders correlated to nutritional deficiencies. Evidence of acute or chronic physical disease implicates significant bidirectional communication involving multiple systems in the body, symptoms of which may suggest the criteria for psychological disorders. Ruling out primary disease processes prevents misdiagnosis of psychological disorders and promotes effective treatment.
Normal range for test. Critical values for total calcium are less than 6.0 or greater than 13 mg/dl or less than 1.5 or greater than 3.25 mmol/L (SI units). Critical values for ionized calcium are less than 2.2 or greater than 7.0 mg/dl or less than .78 or greater than 1.57 mmol/L (SI units). Normal findings for total calcium in adults are 9-10.5 mg/dl or 2.25-2.75 mmol/L. Normal findings for total calcium in children varies by age: Less than 10 days, 7.6-10.4 mg/dl or 1.9-2.6 mmol/L; 10 days – 2 years, 9-10.6 mg/dl or 2.3-2.65 mmol/L; child over 2 years, 8.8-10.8 mg/dl or 2.2-2.7 mmol/L. Ionized calcium levels are normally 4.5-5.6 mg/dl or 1.05-1.30 in adults. Newborns normally have ionized calcium levels of 4.2-5.58 mg/dl or 1.05-1.37 mmol/L, and children 2 months to 18 years, 4.8-5.52 mg/dl or 1.2-1.38 mmol/L (Pagana & Pagana, 2002, p.146).
Meaning of values above and below the range. Significant serum calcium elevation (i.e., hypercalcemia) may be demonstrated through symptoms of anorexia, nausea, vomiting, somnolence, or coma. Primary causes of hypercalcemia are hyperparathyroidism, malignancy (nonparathyroid PTH-producing tumors), bone tumors, mild-alkali syndrome, Vitamin D intoxication, lymphoma, infections such as sarcoidosis and tuberculosis, Addison’s disease, acromegaly, and hyperthyroidism. Lower levels of calcium or hypocalcemia occur in patients with hypoalbuminemia. The most common cause of hypoalbuminemia is malnutrition in alcoholics. Other causes of decreased calcium levels include hypoparathyroidism, rickets, Vitamin D deficiency, intestinal malabsorption, renal failure, alkalosis, pancreatitis, fat embolism, and alkalosis (Pagana & Pagana, 2002, p.149-150).
Cautions necessary in interpreting test results. Factors that interfere with test results include Vitamin D intoxication and excessive eating and drinking of milk products which results in serum calcium levels. Diurnal variations of serum calcium occur, usually peaking in the evening. Decreased serum pH can cause serum calcium decreases, and hypoalbuminemia can result in decreased total calcium levels. Drugs causing increased levels include calcium salts, hydralazine, lithium, alkaline antacids, thyroid hormones, androgens, and vitamin D. Drugs causing decreased calcium levels include acetazolamide, anticonvulsants, aspirin, corticosteroids, heparin, laxatives, estrogens, and contraceptives (Pagana & Pagana, 2002, p.148).
Serum Sodium (Na)
Test explanation. Sodium evaluation determines electrolyte balance. Blood content of sodium results from the balance of sodium intake ad renal excretion. Factors that influence sodium levels include aldosterone, natriuretic hormone, and antidiuretic hormone (ADH). Symptoms of hyponatremia (inadequate sodium) occur with sodium levels are below 125 mEq/L, and the primary symptom is weakness. If the level drops below 115 mEq/L, confusion, lethargy, and coma can result. Hypernatreia (excessive sodium) results in dry mucous membranes, thirst, agitation, restlessness, hyperreflexia, and mania (Pagana & Pagana, 2002, p. 424).
Psychological difficulties associated with this test. Sodium is a critical electrolyte which regulates fluid balances inside and surrounding cells in the body. Fluid imbalances promote kidney, liver, and adrenal dysfunction, and fluid balances support brain process, promote cognitive functioning, and are instrumental in maintaining emotional homeostasis. Kidney, liver, or adrenal function abnormality impacts neurochemical processes and affects emotional and behavioral regulation. This disruption would promote symptoms mimicking psychological disorders. Sodium balances have been implicated in studies of chronic fatigue syndrome, dementia, and premenstrual syndrome (Werbach, 1999). The agitation, restlessness, and mania present with hypernatreia could easily be assessed as symptoms of anxiety, bipolar disorder, or ADHD and promote a misdiagnosis of a psychological disorder.
Normal range for test. Critical values for Na are less than 120 or greater than 60 mEq/L. Normal serum sodium levels in adults and the elderly are 136-145 mEq/L or 136/145 mmol/L (SI units). In newborns normal levels are 134-144 mEq/L; in infants, 134-150 mEq/L; and in children 136-145 mEq/L (Pagana & Pagana, 2002, p.423).
Meaning of values above and below the range. Increased blood sodium levels may indicate increased sodium intake (e.g., diet, IV fluids), decreased sodium loss (e.g., Cushing’s syndrome, hyperaldosteronism), or increased free body water loss (e.g., excessive sweating, burns, diabetes insipidus, osmotic diuresis). Decreased blood sodium levels may indicate decreased sodium intake (e.g., diet, IV fluids), increased sodium loss (e.g., Addison’s disease, diarrhea, vomiting, bowel loss, diuretics, renal insufficiency, aspiration of pleural or peritoneal fluid), or increased free body water (excessive water intake, hyperglycemia, excessive IV water intake, congestive heart failure, ascites, peripheral edema, and oversecretion of ADH (Pagana & Pagana, 2002, p.425-426).
Cautions necessary in interpreting test results. Trauma, surgery, and shock can interfere with levels of blood sodium. Renin and angiotensin can increase renal absorption of sodium. Some drugs increase sodium levels, and these include anabolic steroids, antibiotics, clonidine, corticosteroids, cough medicines, laxatives, estrogens, and contraceptives. Some drugs decrease sodium levels such as carbamazepine, diuretics, enzyme inhibitors, haloperidol, heparin, and tricyclic antidepressants (Pagana & Pagana, 2002, p.424).
Serum Potassium (K)
Test explanation. Abnormal levels of potassium are usual evaluated in any serious illness, especially because it is critical to heart function. Intracellular potassium levels of 150 mE1/L and serum levels of 4 mEq/L are the approximate normal, and the ratio between the two determines electrical potential. Potassium is critical to protein synthesis and important in the maintenance of other physiologic functions. Potassium concentration depends on factors such as hormones (i.e., aldosterone and glucocorticosteroids), reabsorption of sodium, and acid-base balances (i.e., alkalotic and acidotic states). Symptoms of hyperkalemia include irritability, nausea, vomiting, coli c, and diarrhea. Hypokalemia is seen symptoms such as weakness, paralysis, hyporeflexia, and cardiac arrhythmias. Potassium levels need to be closely monitored in individuals with Addison’s disease, taking digitalis-like drugs, taking steroid therapy, or potassium-depleting diuretics (Pagana & Pagana, 2002, p.372-373).
Psychological difficulties associated with this test. Potassium is important in physical functions such as regulation of blood pressure, maintaining water content in cells, nerve transmission, digestion, muscle contraction, and heartbeat. Potassium deficiency is potentially fatal. Abnormalities in potassium contribute to presenting symptoms mimicking psychological disorders such as aggression, alcoholism, anxiety, bipolar disorder, depression, eating disorders, fatigue, and insomnia (Werbach, 1999). Increased potassium levels can denote the presence of diseases such as hypothyroidism and uncontrolled diabetes and conditions such as malnutrition, malabsorption, and stress that affect the individual’s ability to balance and maintain psychological equilibrium. Emotional and behavioral dysregulation can result in symptoms indicative of psychological disorders and contribute to misdiagnosis. Medications prescribed for medical and psychological disorders (e.g., insulin, laxatives, lithium) can cause potassium depletion and further compound the potential for diagnostic confusion.
Normal range for test. Critical blood potassium levels are less than 2.5 or greater than 6.5 mEq/L in adults and less than 2.5 or greater than 8.0 mEq/L in newborns. Normal findings in adults and the elderly are 3.5-5.0 mEq/L or 3.5-5.0 mmol/L (SI units); in children, 3.4-4.7 mEq/L; in infants, 4.1-5.3 mEq/L; and in newborns, 3.9-5.9 mEq/L (Pagana & Pagana, 2002, p.372).
Meaning of values above and below the range. Hyperkalemia (increased potassium levels) indicate excessive dietary or IV intake of potassium, renal failure, Addison’s disease, hypoaldosteronism, aldosterone-inhibiting diuretics, hemolysis, infection (cellular injury and lysis causes release of potassium into blood), acidosis, and dehydration. Hypokalemia or decreased potassium levels indicate deficient dietary or IV potassium intake, burns, GI disorders (e.g., diarrhea, vomiting), diuretics, hyperaldosteronism, Cushing’s syndrome, renal acidosis, alkalosis, insulin for hyperglycemia (potassium levels drop), glucose administration, ascites, renal artery stenosis, cystic fibrosis, and trauma (i.e., aldosterone mediates physical response to trauma resulting in increased potassium excretion) (Pagana & Pagana, 2002, p.374-375).
Cautions necessary in interpreting test results. Some factors that may confound test results occur during the test itself. For example, opening and closing the hand when a tourniquet has been applied may result in increased potassium levels. Also, hemolysis of blood during the venipuncture or during processing in the laboratory can increase potassium levels. Some drugs increase potassium levels, and these include antibiotics, epinephrine, heparin, histamine, lithium, potassium-sparing diuretics, and succinylcholine. . Some drugs decrease potassium level, and these include glucose infusions, potassium-wasting diuretics, insulin, laxatives, lithium, and aspirin (Pagana & Pagana, 2002, p.373).
Test explanation. Cholesterol is required for production of steroids, sex hormones, bile acids, cellular membranes, and is the main lipid involved in heart disease. Approximately 75% of cholesterol binds to low-density lipoproteins (LDL) and 25% to high-density lipoprotein (HDL). Cholesterol testing identifies patients at high risk for cardiovascular disease, and LDL is most associated with disease processes. Cholesterol levels vary up to 15% on a daily basis. Because of the liver’s responsibility in the metabolism of cholesterol, high cholesterol levels also indicate liver disease. Malnutrition is also associated with low levels of cholesterol because the diet is the main source of cholesterol (Pagana & Pagana, 2002, p.160).
Psychological difficulties associated with this test. Abnormal cholesterol levels may indicate either hypo or hyperthyroidism, uncontrolled diabetes, heart disease, liver disease, cancer, malnutrition and malabsorption, or stress. Individuals with elevated cholesterol levels are generally instructed to restrict dietary fat consumption; however, studies show heightened depression rates in individuals on these dietary regimens (Healthnotes, 2006). Cholesterol level also denotes thyroid dysfunction, and most patients with thyroid deficiencies present with depressive symptoms. Thyroid dysfunction results in dysregulation in a number of other physiological processes such as metabolism of carbohydrate, protein, and fat; utilization of vitamins; digestion; blood flow; hormone secretion; and mitochondrial function (Genova Diagnostics, 2005). Diabetes promotes dysregulation in glucose processes which are associated with aggression, anxiety, depression, and ADHD. Malnutrition or malabsorption of ingested nutrients contributes to psychological disorders such as aggression, alcoholism, eating disorders, ADHD, bipolar disorder, dementia, depression, and schizophrenia (Werbach, 1999). Chronic disease states dysregulate physiological systems and may mimic psychological disorders. Stress, due to (a) its complex interrelationships with organs and neurochemical processes and (b) inherent bidirectional communication and feedback loops, initiates and exacerbates psychological disorders. Studies show that high cholesterol levels negatively impact brain function and are strongly correlated with affective disorders, including depression, bipolar disorder, and schizoaffective disorder, and hostility and aggression (ReduceTriglycerides.com, 2005).
Normal range for test. Adults and elderly will have normal cholesterol levels of less than 200 mg/dl or less than 5.20 mmol/L (SI units). Children will have cholesterol findings of 120-200 mg/dl; infants, 70-175 mg/dl; and newborns, 53-135 mg/dl (Pagana & Pagana, 2002, p.160).
Meaning of values above and below the range. Increased cholesterol levels can indicate such conditions as familial hypercholesterolemia, familial hyperlipidemia, hypothyroidism, uncontrolled diabetes, high-cholesterol diet, hypertension, myocardial infarction, atherosclerosis, cirrhosis, and stress. Decreased cholesterol levels may indicate malabsorption, malnutrition, advanced cancer, hyperthyroidism, anemia, stress, liver disease, and acute myocardial infarction (Pagana & Pagana, 2002, p. 162-163).
Cautions necessary in interpreting test results. Pregnancy results in elevated levels of cholesterol. Postmenopausal status also affects cholesterol levels. Some drugs increase cholesterol levels such as adrenocorticotropic hormone, anabolic steroids, beta-adrenergic blockers, corticosteroids, epinephrine, contraceptives, Dilantin, and vitamin D. Some drugs decrease cholesterol levels such as androgens, chlorpropamide, clofibrate, erythromycin, Cytomel, Mevacor, monoamine oxidase inhibitors, niacin, and nitrate (Pagana & Pagana, 2002, p.161).
Serum Triglycerides (TG)
Test explanation. TGs are a form of fat in the bloodstream and identify coronary disease risk. TGs are transported in very-low-density lipoproteins (VLDSs) and LDLs. They are produced in the liver, and when high, are deposited in the body’s fat tissue, constituting most of the body’s fat (Pagana & Pagana, 2002, p. 456).
Psychological difficulties associated with this test. Nutrition has a critical influence on the brain due to its neurochemical and metabolic interactions involved. Nutrition neuroscience correlates diets high in fat to elevated depression. High blood levels of triglycerides are implicated in a number of affective and behavioral disorders, and the mechanism involved is thought to be the slowed function of blood with high triglyceride content, increasing difficulty in oxygen transport and promoting brain lesions and blood clots. These are hypothesized to cause symptoms of organic brain syndrome which includes affective behavior such as depression and hostility. Triglycerides are also implicated in the process of insulin resistance as carbohydrate ingestion negatively impacts neurochemical processes (ReduceTriglycerides.com, 2005). Increased triglyceride levels are involved in hypo and hyperthyroidism, diet, and diabetes. Most patients with thyroid deficiencies present with depressive symptoms, and thyroid dysfunction results in dysregulation of a number of other physiological processes such as metabolism of carbohydrate, protein, and fat; utilization of vitamins; digestion; blood flow; hormone secretion; and mitochondrial function (Genova Diagnostics, 2005). Diabetes promotes dysregulation in glucose processes and is correlated with aggression, anxiety, depression, and ADHD. Malnutrition or malabsorption of ingested nutrients contributes to psychological disorders such as aggression, alcoholism, eating disorders, ADHD, bipolar disorder, dementia, depression, and schizophrenia (Werbach, 1999). Chronic disease states dysregulate physiological systems and may mimic psychological disorders. Stress, due to (a) its complex interrelationships with organs and neurochemical processes and (b) inherent bidirectional communication and feedback loops, initiates and exacerbates psychological disorders (ReduceTriglycerides.com, 2005)
Normal range for test. Critical values for TGs are above 400 mg/dl. Normal findings in adults and elderly differ for men and women. For men, normal findings are 40-160 mg/dl or .45-1.81 mmol/L (SI units). For women, normal findings are 35-135 mg/dl or .40-1.52 mmol/L (SI units). Findings in children also differ for boys and girls. For boys 0-5 years, the normal finding is 30-86 mg/dl; for 6-11 years, 31-108 mg/dl; for 12-15 years, 36-138 mg/dl; and for 16-19 years, 40-163 mg/dl. For girls 0-5 years, normal findings are 32-99 mg/dl; for 6-11 years, 35-114 mg/dl; for 12-15 years, 41-138 mg/dl; and for 16-19 years, 40-128 mg/dl (Pagana & Pagana, 2002, p.456).
Meaning of values above and below the range. Increased levels of TGs may indicate glycogen storage disease such as von Gierke’s disease, familial hypertriglyceridemia, apoprotein C-II deficiency, hyperlipidemias, hypolipidemias, hypothyroidism, high-carbohydrate diet, diabetes, nephritic syndrome, and renal failure. Decreased TG levels may indicate malabsorption syndrome, abetalipoproteinemia, malnutrition, and hyperthyroidism (Pagana & Pagana, 2002, p.457-458).
Cautions necessary in interpreting test results. Eating fatty foods and drinking alcohol can increase TG levels. Pregnancy also results in increased TG levels. Some drugs that increase TGs are cholestyramine, estrogens, and oral contraceptives. Some drugs that may decrease TGs are ascorbic acid, asparaginase, and clofibrate (Pagana & Pagana, 2002, p.456-457).
Serum Free Thyroxine (FT4)
Test explanation. The FT4 test evaluates thyroid function. More than 90% of thyroid hormone is composed of thyroxine (FT4). Most of this is bound to proteins, and only 1-5% is metabolically active (i.e., free). Both bound and free are measured, but the free T4 is a more accurate indicator of thyroid function. Increased FT4 levels indicate hyperthyroid states, while decreased levels indicate hypothyroid states (Pagana & Pagana, 2002, p. 445-446).
Psychological difficulties associated with this test. The FT4 test measures thyroid function, and both hypo and hyperthyroidism is implicated in depression. Most patients presenting with thyroid dysfunction also meet criteria for depressive disorder. Hypothyroid states may indicate pituitary deficiency, iodine deficiency, or physical diseases such as cirrhosis and advanced cancer, renal failure. The pituitary gland is the body’s master gland and secretes many hormones necessary to optimal function, acting as messengers to stimulate other glands. Hormones produced by the pituitary include prolactin, growth hormone (GH), adrenocorticotropin (ACTH), thyroid-stimulating hormone (TSH), antidiuretic hormone (vasopressin), luteinizing hormone (LH), and follicle-stimulating hormone (FSH). GH is critical to the maintenance of muscle mass, bone mass, and fat distribution. ACTH is critical to cortisol production, the stress hormone involved in the body’s fight or flight response. ACTH helps maintain blood pressure and blood glucose levels. TSH stimulates the thyroid gland, essential to metabolism, energy, growth, and nervous system activity. ADH regulates water balance, critical to kidney function. LH and FSH work together in regulation of the reproductive system (Hormone Foundation, 2006). Dysregulation in any system involved in pituitary hormonal function may result in symptoms mimicking those of psychological disorders. Excess dietary iodine may induce hypothyroidism and result in eating disorders (Werbach, 1999). Iodine deficiency is implicated in impairment of intellectual and neuromotor functioning in normal children, with the potential of misdiagnosis of learning disorders (Werbach). Acute or chronic disease states may initiate or exacerbate symptoms mimicking psychological disorder, resulting in potential misdiagnosis.
Normal range for test. Normal findings for adults are .8-2.8 ng/dl or 10-36 pmol/L (SI units). Normal levels for infants 0-4 days are 2-6 ng/dl or 26-77 pmol/L (SI units); and for infant, child, adolescence, normal findings are .8-2 ng/dl or 10-26 pmol/L (SI units) (Pagana & Pagana, 2002, p.445).
Meaning of values above and below the range. Increased levels of FT4 may indicate primary hyperthyroid states (e.g., Graves’ disease, Plummer’s disease), acute thyroiditis, factitious hyperthyroidism (patient-administered thyroid for energy or weight loss), or ectopic thyroid tissue. Decreased levels of FT4 may indicate hypothyroid states (e.g., cretinism, myxedema), pituitary or iodine insufficiency, and nonthyroid disease (e.g., renal failure, Cushing’s disease, cirrhosis, advanced cancer) (Pagana & Pagana, 2002, p.447).
Cautions necessary in interpreting test results. Infants have higher levels. If radioisotopes have previously been used, test results will be compromised. Patient-administered thyroxine increase FT4 levels. Some drugs that increase FT4 levels include heparin, aspirin, and propranolol. Drugs that decrease levels include methadone, rifampicin, furosemide, and phenytoins (Pagana & Pagana, 2002, p.446).
Serum Total Thyroxine (T4, Thyroxine Screen)
Test explanation. The serum T4 test is used to diagnose thyroid function and directly measures the total amount of T4 in the blood, both bound and free. Thyroid hormones are made of almost completely of T4 (T 3 = approximately 10% of thyroid hormone). Thyrotropin-releasing hormone (TRH), secreted by the hypothalamus, initiates the release of thyroid-stimulating hormone (TSH) by the pituitary. This results in the thyroid secreting thyroid hormone. Increased levels of T4 suggest hyperthyroid condition and decreased levels suggest hypothyroid condition (Pagana & Pagana, 2002, p.451).
Psychological difficulties associated with this test. Abnormal levels of T4 indicate thyroid imbalances, malnutrition, and iodine deficiencies. Imbalances may also indicate patient ingestion of drugs such as heroin, amphetamines, or methadone or that the patient is using the lithium as a mood stabilizer. Thyroid imbalances generally present with co-occurring depression. Nutritional deficiencies associated with psychological disorders include aggression, alcoholism, eating disorders, anxiety, ADHD, bipolar disorder, dementia, depression, obsessive compulsive disorder, and schizophrenia (Werbach, 1999). Iodine deficiency is implicated in impairment of intellectual and neuromotor functioning in normal children, with the potential of misdiagnosis of learning disorders (Werbach). Decreased levels of T4 may indicate pituitary insufficiency. The pituitary gland is the body’s master gland, secreting many hormones necessary to optimal function (i.e., GH, ACTH, TSH, LH, FSH, prolactin, vasopressin), and dysregulation in any pituitary hormonal function may result in symptoms mimicking psychological disorders. As the hypothalamus is critical to emotion, and behavior, dysregulation and system failure initiates symptoms indicative of psychological disorders. Any chronic disease state is likely to elicit symptoms meeting criteria for psychological disorders due to the interrelationships of all systems in the stress response and in neurobiological functioning.
Normal range for test. Critical values T4 in adults are less than 2.0 ?g/dl if possibility of myxedema coma and greater than 20 ?g/dl if possibility of thyroid storm. Critical values for a newborn is less than 7.0 ?g/dl (Pagana & Pagana, 2002, p.450-451).
Meaning of values above and below the range. Increased levels of T4 indicate the possibility of primary hyperthyroid conditions such as Graves’ disease, Plummer’s disease, and toxic thyroid adenoma. Increases may also indicate acute thyroiditis, familial dysalbuminemic hyperthyroxinemia, factitious hyperthyroidism, or ectopic thyroid tissue. Thyroxine-binding globulin (TBG) must also be measured because elevations in these levels can occur during pregnancy or when the individual has hepatitis or congenital hyperproteinemia and cause elevated levels of T4. Decreases in levels of T4 result can indicate hypothyroid conditions such as cretinism or myxedema, pituitary insufficiency, hypothalamic failure, protein malnutrition, iodine insufficiency, or nonthyroid diseases (e.g., renal failure, Cushing’s disease, cirrhosis, or cancer) (Pagana & Pagana, 2002, p.453).
Cautions necessary in interpreting test results. Both pregnancy and the individual having had a previous iodinated contrast x-ray study will increase the T4 levels. Some drugs will increase the test levels (e.g., iodine, estrogens, heroin, amphetamines, methadone, and oral contraceptives), and some drugs will decrease test levels (e.g., anabolic steroids, barbiturates, androgens, antithyroid drugs, lithium, Dilantin, and Inderal (Pagana & Pagana, 2002, p.452).
Test explanation. Immunoglobulins are antibodies made up of gamma globulin protein, and testing immunoglobulins assists in the diagnosis of many diseases. Classes of immunoglobulins include IgG (about 75%), IgA (15%), IgM, IgE, and IgD. IgA is primarily in the respiratory and GI tract, saliva, and tears. IgM is responsible for ABO blood grouping and rheumatoid factor. IgE mediates allergic responses. IgD is rare. Serum immunoelectrophoresis detects hypersensitivity diseases, immune deficiencies, autoimmune diseases, and chronic infections (Pagana & Pagana, 2002, p. 295).
Psychological difficulties associated with this test. Serum immunoelectrophoresis detects the presence of IgG and IgE antibodies. IgE antibodies are associated with Type 1 food allergies which occur in less than 5% of the population. In Type 1 food allergies, when the allergic food is ingested (after the initial binding occurs), histamine and other chemicals are released, resulting in severe symptoms which can be life-threatening (i.e., stomach cramping, diarrhea, rashes, swelling, wheezing, or anaphylaxis). IgE food allergens have an immediate effect and are over-reactions (allergies) of the body’s immune system, primarily affecting the skin, air passages, and digestive tract. IgG antibodies are involved in Type 3 immune reactions, also called food intolerances, and the antibodies bind directly to the food and result in delayed symptoms. However, IgG food allergies can affect all systems of the body (e.g., brain, joints, muscles, glands, lungs, kidneys, nervous system) and can be linked to over 100 medical conditions (Braley, 2006).
Food allergies upset hormone and other brain chemical levels and can result in symptoms of depression, schizophrenia, and other psychological disorders. Children with allergies may be irritable, hyperactive, and unable to concentrate, and meet criteria for ADHD. Daily mood swings can be a symptom of cerebral allergies and can manifest as mania, depression, paranoia, and abnormal thinking processes. Patients with food allergies may also have pyroluria (Pfeiffer, 1987) Hidden food sensitivities are linked to many psychiatric disorders, including celiac disease (i.e., allergy to wheat, rye, and other grains) which results in malabsorption. Individuals present with symptoms of obsessive/compulsive behaviors, impaired speech development, and behavior changes (Pfeiffer, p. 53). Symptoms for celiac disease and schizophrenia are similar, and mood behavior swings after ingesting cereal grains is common. Individuals diagnosed with schizophrenia need to be assessed for gluten-sensitivity (Pfeiffer).
Normal range for test. Normal findings in adults for IgG are 565-1765 mg/dl, and levels vary in children according to age. An infant of one month would have a normal finding of 250-900 mg/dl; 2-5 month, 200-700 mg/dl; 6-9 month, 220-900 mg/dl; 1 year, 340-1200 mg/dl; 2-3 years, 420-1200 mg/dl; and 4-12 years, 460-1600 mg/dl. Normal findings for IgE are usually minimal (Pagana & Pagana, 2002, p. 294).
Meaning of values above and below the range. Increased in IgG levels may indicate hyperimmunization reactions, chronic liver disease, or autoimmune diseases. Decreases in IgG levels may indicate Wiskott-Aldrich syndrome, AIDS, hypoproteinemia, drug immunosuppression, or leukemia. Increases in IgE levels may indicate allergic reactions such as hayfever, asthma, eczema, or anaphylaxis or allergic infections such as aspergillosis, or parasites. Decreases in IgE levels may indicate agammaglobulinemia (Pagana & Pagana, 2002, p. 296-297).
Cautions necessary in interpreting test results. Drugs may increase immunoglobulin levels (e.g., hydralazine, Dilantin, oral contraceptives, methadone, steroids, and tetanus toxoid and antitoxin (Pagana & Pagana, 2002, p. 295).
Serum Vitamin B12
Test explanation. Testing for vitamin B12 is critical because of its role in converting folate from its inactive to its active form, a necessary process for synthesizing nucleic and amino acids. Insufficient B12 causes anemia because of its function in forming RBCs. Common causes for B12 deficiency are insufficient intrinsic factor (IF), insufficient gastric acid, and malabsorption caused by disease states (Pagana & Pagana, 2002, p.475).
Psychological difficulties associated with this test. Increased levels of vitamin B12 indicate the possibility of chronic disease states (e.g., leukemia, liver disease), and decreased levels may indicate chronic conditions such as anemia, malabsorption syndromes, intestinal worms, vitamin C deficiency, or folic acid deficiency (Pagana & Pagana, 2002).Any chronic disease has the inherent tendency to promote co-occurring psychological distress and symptoms which may be misdiagnosed as the primary condition. Nutritional malabsorption, worms, and nutritional deficiency (i.e., vitamin C, folic acid) will result in symptoms mimicking psychological disorders. Nutritional factors have been correlated with psychological disorders such as aggression, alcoholism, eating disorders, anxiety, ADHD, bipolar disorder, dementia, depression, and schizophrenia (Werbach, 1999). Vitamin C deficiency has been associated with aggression, alcoholism, anxiety, autism, bipolar disorder, chronic fatigue, dementia, depression, eating disorders, fatigue, learning disorders, and schizophrenia (Werbach). Abnormal levels of folic acid have been correlated to alcoholism, autism, bipolar disorder, chronic fatigue, dementia, depression, eating disorders, fatigue, and schizophrenia (Werbach).
Normal range for test. Normal findings for vitamin B12 are 160-950 pg/ml or 118-701 pmol/L (SI units) (Pagana & Pagana, 2002, p.475).
Meaning of values above and below the range. Increased levels of vitamin B12 indicate the possibility of leukemia, polycythemia vera, severe liver disease, and myeloproliferative disease. Decreased levels may indicate pernicious anemia, malabsorption syndromes (e.g., inflammatory bowel disease, sprue, Crohn’s disease), intestinal worms, atrophic gastritis, Zollinger-Ellison syndrome, proximal gastrectomy, achlorhydria, vitamin C deficiency, and folic acid deficiency. Vitamin B12 deficiency sometimes occurs during pregnancy because of inadequate nutritional intake (Pagana & Pagana, 2002, p.476).
Cautions necessary in interpreting test results. Factors that interfere with accurate test results include (a) presence of chloral hydrate which increases B12 levels and (b) drugs that decrease B12 levels such as alcohol, aminoglycosides, aminosalicylic acid, anticonvulsants, and oral contraceptives (Pagana & Pagana, 2002, p.475).
Essential Urine Tests
alpha-Aminolevulinic Acid (ALA, (alpha-ALA)
Test explanation. The alpha-ALA is used to diagnose porphyria and lead poisoning. As the precursor for porphyrins, alpha-ALA is involved in the synthesis of heme which is used in hemoglobin synthesis. Porphyria has been associated to dysfunction in heme metabolism. Liver porphyrias cause symptoms such as abdominal pain, neuromuscular problems, constipation, and sometimes psychotic behavior. Symptoms during the acute phase of porphyria may demonstrate mental symptoms such as anxiety, insomnia, hallucinations, and paranoia (Pagana & Pagana, 2002, p.865).
Psychological difficulties associated with this test. Porphyria is known to be believed to be a causative factor in schizophrenia (Pfeiffer, 1987). Associated symptoms (i.e., psychotic behavior, hallucinations, paranoia) mimic schizophrenia and misdiagnosis can occur. Anxiety associated with porphyria may also be misdiagnosed as anxiety disorder.
Normal range for test.
values for alpha-ALA are less than 20mg/24 hours. Normal findings are
mg/24 hours or 11-57 ?mol/24 hours (SI units) (Pagana & Pagana,
Cautions necessary in interpreting test results. Drugs that interfere with ALA test results include penicillin, barbiturates, and griseofulvin (Pagana & Pagana, 2002, p.865).
Test explanation. The 17-OCHS test assesses adrenocortical function. Elevations denote adrenal hyperfunction such as in Cushing’s syndrome. Low levels of 17-OCHS indicate adrenal hypofunction such as in Addison’s disease (Pagana & Pagana, 2002, p.869).
Psychological difficulties associated with this test. Adrenocortical function is critical to homeostatic balance. Adrenal gland secretion of epinephrine and glucocorticoids (i.e., cortisol) maintains this homeostasis. Studies report that dysfunction in this system results in psychological disorders (e.g., aggression, depression, anxiety) which may be misdiagnosed as the primary condition. Abnormal levels of 17-OCHS indicate the possibility of thyroid dysfunction which mimics medical and psychological conditions including fatigue, depression, headaches, premenstrual syndrome, anxiety, panic attacks, deficits in memory and concentration, muscle and joint pain, and sex drive (Genova Diagnostics, 2005).
Normal range for test. Normal findings in adult males are 3-10 mg/24 hours or 8.3-27.6 ?mol/day (SI units). Normal findings for adult females are 2-8 mg/24 hours or 5.2-22.1 ?mol/day (SI units). Findings for the elderly are slightly lower than those for adults. Normal values for children under 8 years old are less than 1.5 mg/24 hours; and children 8-12 years, less than 4.5 mg/24 hours (Pagana & Pagana, 2002, p.869).
Meaning of values above and below the range. Increased levels of 17-OCHS may indicate Cushing’s syndrome or disease, ACTH-producing tumors due to overproduction of ACTH, stress (cortisol and 17-OCHS levels rise during stress response), hyperthyroidism, or obesity. Decreased 17-OCHS levels may indicate adrenal hyperplasia, Addison’s disease, hypopituitarism (insufficient ACTH, cortisol, and 17-OCHS), or hypothyroidism (Pagana & Pagana, 2002, p. 870-871).
Cautions necessary in interpreting test results. Emotional stress, physical infection, and eating licorice can cause increases in adrenal activity. Drugs that may cause increases in 17-OCHS include acetazolamide, chloral hydrate, chlorpromazine, erythromycin, meprobamate, paraldehyde, quinidine, and quinine. Drugs that may decrease levels include estrogen, oral contraceptives, and reserpine (Pagana & Pagana, 2002, p.870).
Substance Abuse Testing
Test explanation. Substance abuse testing identifies metabolites of illegal drugs remaining in the individual’s system. Drug screens test for amphetamines, barbiturates, benzodiazepines, cocaine, methamphetamine, opiates, THC, PCP, and alcohol. Urine screening uses enzyme multiplied immunoassay (EMIT) or radio immunoassay (RIA).
Psychological difficulties associated with this test. Substance use screening is utilized to determine use of alcohol or illicit drugs, and the test is normally utilized by agencies working with individuals meeting criteria for substance use or substance dependency. When an individual is mood-altered by alcohol or drugs (AOD) he may present with symptoms that meet criteria for psychological disorders. Many AOD affected individuals are misdiagnosed, given psychiatric medication, and carry this misdiagnosis with them. When I evaluate placement of residential AOD clients, it is not unusual to have two or three assessments having different diagnoses different sources. For example, the effects of alcohol and depressants may be misdiagnosed for depression or bipolar disorder; effects of stimulants as ADHD, bipolar disorder, schizoaffective, or schizophrenia; and effects of hallucinogens, psychosis. It is critical to provide adequate detoxification prior to diagnosing an AOD addicted individual in order to prevent misdiagnosis.
Normal range for test. Normal findings are negative.
Meaning of values above and below the range. Results above a certain level indicate that the individual has used illegal drugs (or alcohol) in the recent past. The time period for accurate assessment of drug use is dependent on the substance being evaluated.
Cautions necessary in interpreting test results. Poppy seeds can sometimes cause false-positive results for opiate use. Second-hand marijuana smoke can cause false positives for THC use. Ibuprofen can elicit a false positive for THC. Cold remedies can cause false –positive amphetamine results (dependent on cold remedy ingredients). Excessive use of diuretics can decrease urine levels of the drug being tested (Pagana & Pagana, 2002, p.890).
Test explanation. Uric acid testing is usually performed to evaluate uric acid metabolism in gout and to identify individuals who are at risk for stone formation due to uric acid elevations.
Psychological difficulties associated with this test. Heavy metal poisoning may be indicated by increases in uric acid, and it is implicated in a variety of symptoms diagnosed as psychological disorders. Pfeiffer (1987) proposes that a causative factor in schizophrenia is heavy metal toxicity. Mineral imbalances may indicate toxicity and many individuals presenting with physiological dysfunction have abnormal levels of metals. When an individual has a vital metals deficiency, it may be replaced with a toxic metal. Deficiency of the vital metal will result in symptoms that may mimic psychological disorders. Autism has been proposed to be caused by mercury poisoning (Bernard et al., 2000). Studies show that heavy metals (e.g., mercury, cadmium, lead, aluminum, nickel) affect synaptic brain process and nervous system function. They also disrupt brain and cellular calcium levels, affect neurotransmitter release of serotonin, norepinephrine, and acetylcholine, and are implicated in affective disorders, impulsive behaviors, and aggression. Heavy metals also affect the transport and function of essential vitamins and minerals such as magnesium, lithium, zinc, iron, and vitamin B-6 and B-12. These deficiencies result in symptoms mimicking psychological disorders (e.g., depression, anxiety). Heavy metal toxicity is implicated in many other psychological disorders (e.g., autism, ADHD, Many other disorders are implicated including learning disability (e.g., dyslexia), bipolar disorder, schizophrenia, aggression, impulsive disorders, aggression/violence, and juvenile delinquency (Windham, 2006).
Normal range for test. Normal findings for uric acid levels are 250-750 mg/24 hours or 1.48-4.43 mmol/day (SI units) (Pagana & Pagana, 2002, p.895).
Meaning of values above and below the range. Increased levels of uric acid may indicate gout, cancer, leukemia, high-purine diet, uricosuric drugs (e.g., citrate, estrogens, steroids, salicylates, outdated tetracycline), or lead toxicity. Increased uric acid tubular secretion can indicate heavy metal poisoning. Decreased levels of uric acid may indicate kidney disease, eclampsia, chronic alcoholism, or acidosis (diabetic or starvation) (Pagana & Pagana, 2002, p.896-897).
Cautions necessary in interpreting test results. Factors that may interfere with interpretation of uric acid testing includes (a) recent use of radiographic contrast agents and (b) drugs such as alcohol, anti-inflammatory agents, salicylates, thiazide diuretics, and warfarin (Pagana & Pagana, 2002, p.895).
Test explanation. Urinalysis testing can provide information about a significant number of physiological processes and is the most frequently ordered urine test because of its diagnostic capability. Multiple tests are conducted on a urine specimen, and it is evaluated for color, appearance, odor, and pH. Presence and blood levels of proteins, glucose, ketones, blood, RBCs, WBCs, casts, crystals, and bacteria are assessed (Pagana & Pagana, 2002, p. 898).
Psychological difficulties associated with this test. Hypoglycemia and hyperglycemia result in significant emotional distress. The brain is dependent on glucose, and when blood sugar levels drop, irritability, anxiety, depression, confusion, and difficulty concentrating occur. Pfeiffer (1987) states that 20% of schizophrenias are related to nutritional hypoglycemia (Pfeiffer, 1987). Urinalysis may indicate porphyria, and symptoms during acute porphyria may exhibit as anxiety, insomnia, hallucinations, and paranoia (Pagana & Pagana, 2002). Lead intoxication may manifest as amotivation, cognitive impairment, hyperactivity, and behavioral dysregulation, resulting in consequent misdiagnosis. Chronic conditions and disease states (e.g., liver disease, gallbladder disease, urinary infections, renal disease, diabetes, cancer, thyroid dysfunction, tumor, sickle cell disease) present with symptoms that mimic psychological disorders and promote stress responses that exacerbate emotional and mental dysregulation (Pagana & Pagana, 2002).
Normal range for test. Normal appearance of urine is clear with an amber yellow color. The odor is aromatic. The pH level for normal urine is 4.6-8.0 with an average of 6.0. Normal urine protein levels are 0-8 mg/dl, 50-80 mg/24 hour (rest), and less than 250 mg/24 hour (exercise). Specific gravity in normal urine findings are 1.005-1.030 in adults with the most common being 1.010-1.025. In the elderly normal findings for specific gravity will be less. Normal findings for newborns are 1.001-1.020. Normal urine findings will show: (a) negative for leukocyte esterase, (b) no nitrites, (c) no ketones, (d) no bilirubin, (e) no crystals, (f) no casts, (g) no WBC casts, (h) no RBC casts, (i) urobilinogen at 0.01-1.0 Ehrlich units/ml, (j) no glucose for a fresh urine specimen, (k) glucose levels of 50-300 mg/24 hour or 0.3-1.7 mmol/day (SI units) for a 24-hour specimen, (l) WBC levels of 0-4 per low-power field, and (m) less than or equal to 2 RBCs (Pagana & Pagana, 2002, p.897).
Meaning of values above and below the range. Abnormal appearance of urine may be caused by pus, RBCs, bacteria. Abnormal coloration may result from internal bleeding for from dietary intake (e.g., beets, rhubarb). Green urine may indicate pseudomonas infection. Diabetic ketoacidosis may be detected by the smell of acetone. Urinary tract infections may be detected by the resultant foul odor. Fecal odor in urine may indicate an enterovesicle fistula. An alkaline pH may indicate bacteria, urinary tract infection, or high citrus fruit and vegetable diet. Acidic urine may denote metabolic or respiratory acidosis, starvation, dehydration, or dietary intake (e.g., cranberries). Urine pH also identifies crystals. Urine protein may indicate proteinuria (indicator of renal disease), nephritic syndrome, diabetes complication, glomerulonephritis, amyloidosis, and multiple myeloma. Glucose in the urine may indicate porphyria, lead intoxication, alcoholic liver disease, or diabetic ketoacidosis. Specific gravity is evaluative of kidney function and renal disease. Leukocyte esterase screen to detect leukocytes in the urine, indicating urinary tract infection. Nitrite testing screens for urinary tract infections. Ketones in urine may indicate uncontrolled diabetes, hyperglycemia, alcoholic ketoacidosis, fasting or starvation, isopropanol ingestion, or acute febrile illness. Bilirubin in the urine may indicate gallstones, liver injury, or drug toxicity. Urine sediment provides information about the urinary system. Crystals in the urinary sediment are predictive of stone formation. Phosphate and calcium oxalate crystals in the urine may indicate parathyroid abnormality or malabsorption. Casts in the urine may indicate proteinuria. Cellular casts indicate renal disease. Fatty casts indicate nephritic syndrome. Waxy casts indicate decreased urine flow through the renal tubule and are associated with chronic renal disease and renal failure. Waxy casts are also present with diabetic nephropathy, malignant hypertension, and glomerulonephritis. Epithelial cells and casts may indicate the possibility of tumor, infection, or polyps. WBCs and casts (n > 5) indicate urinary tract infection and are commonly found in acute pyelonephritis, poststreptococcal glomerulonephritis, or inflammatory nephritis. RBCs and casts may indicate bladder, ureteral, or urethral disease or pathologic conditions (e.g., tumor, trauma, stone, infection) involving the mucous membrane and causing hematuria. RBC casts may also suggest the possibility of bacterial endocarditis, renal infarct, Goodpasture’s syndrome, sickle cell disease, interstitial nephritis, or renal trauma or renal tumor (Pagana & Pagana, 2002, p.898-903).
Cautions necessary in interpreting test results. Factors that may compromise appearance and color include sperm in the urethra, refrigeration of urine longer than an hour, ingestion of certain foods (e.g., carrots, beets, rhubarb), darkening due to oxidation, and certain drugs. Odor can be affected by certain foods (e.g., asparagus) and due to decomposition when it is left standing. Urine pH levels will become alkaline when urine is left standing, and when it is uncovered, allowing carbon dioxide vaporization. Diet affects urine pH (e.g., citrus fruit, dairy products, cranberries, meat). Some drugs increase urine pH (e.g., bicarbonate antacids). Some drugs decrease urine pH (e.g., ammonium chloride). Protein levels may be affected by emotional stress or excessive exercise. Prostate or vaginal secretions contaminate urine. Urine concentration may affect protein level. Hemoglobin and Bence-Jones protein are affected with the dipstick method. Some drugs increase protein levels (e.g., aminoglycosides, colistin, lithium, nafcillin, oxacillin, penicillin G, salicylates). Gravity may be compromised by recent use of radiographic dyes, cold, and drugs such as dextran or sucrose. Leukocyte esterase may have false-positives when specimens are contaminated by vaginal secretions containing WBCs when high levels of protein or ascorbic acid are present. Diet may compromise accuracy in ketone levels, and drugs (e.g., isopropanol, levodopa, paraldehyde) may cause false-positives. Because bilirubin is not stable in urine, it is not necessarily a valid measure. The pH level affects urobilinogen levels, with alkaline urine indicating higher levels, and acidic urine indicating lower levels. Pyridium will color the urine orange, giving the impression of jaundice. Cholestatic drugs decrease urobilinogen levels. Antibiotics reduce urobilinogen levels due to reduced intestinal flora. Urinary crystals may be caused by radiographic contrast media. WBCs in vaginal discharge may contaminate the specimen, providing false report of urine WBCs. RBC levels may be compromised by strenuous physical exercise (causing RBC casts), traumatic urethral catherization (causing RBCs in urine), and aggressive anticoagulant therapy. The most common cause of urine RBCs results from female menses (Pagana & Pagana, 2002, p.903-905).
Hair Mineral Analysis
Utility of hair mineral analysis. Hair tissue mineral analysis (HTMA) can assess intracellular activity in ways that cannot be accomplished with either blood or urine screens. Because biological history is contained in the hair follicle in its process of growth, it is possible to determine biochemical factors not accessible through blood or urine. The ability of HTMA to test for trace minerals provides information regarding a range of metabolic processes. Minerals interact with other minerals and with vitamins, proteins, carbohydrates, and fats in a synergistic relationship. Mineral imbalances can occur for many reasons (e.g., diet, stress, medication, pollution, supplements, genes), and early identification promotes intervention that may prevent future disease processes.
Test explanation. Hair mineral analysis is capable of detecting (a) mineral deficiencies, (b) mineral excesses, (c) toxicity, and (d) metabolic disturbances (Tamari, 2004).
Procedure. Standardized procedures are essential in providing valid, reliable results. The hair specimen is cut into approximately .125 inch pieces and mixed together to provide a representative sub-sample. It is then washed four times with a 1:200 solution of Triton X-100. Samples are then washed in acetone, drained, rinsed three times with de-ionized water, and twice with acetone. Samples are then dried in an oven at 75 (± 5°) C (Bass, 2001). Bland (1984) promulgates a technique of a small amount (1 gram) taken from the suboccipital area of the patient’s scalp, digest it in acid or a similar medium, and analyze the sample by either atomic absorption spectrophotometry or plasma jet spectrophotometry assess the presence of either essential and toxic minerals. He also suggests that several hundred hairs be collected in order to obtain a valid sample. Bland views HTMA as a complement to blood and urine analyses and argues that the procedure is less invasive. He also points out that trace minerals accumulate in the hair at higher concentrations and provide a continuous record of both nutrition and toxic exposure.
Criticisms of HTMA. HTMA has been challenged for the following reasons: (a) variation due to color and beauty treatment, (b) changes in trace element levels due to washing procedures, (c) environmental factors, (d) non-specific relationship between mineral level and tissue sample, (e) variation in quality control (Bland, 1984, p. 11). Studies have no significant relationship between hair color and trace mineral level. Results remain constant when standardized washing procedures are followed. Exogenous materials tend to wash out, while endogenous materials (the minerals being assessed) remain within the hair follicle. Because serum and urine evaluate different trace levels (i.e., one is from a given point in time, while the other assesses over time), it is not possible to have consistently correlated results. This clarifies the reason for variety in testing methods. Regarding quality control, it is critical that laboratories highly specialized, using standardized, regulated procedures be utilized for the testing process.
Advantages of HTMA.
HTMA include: (a) long-term exposure, (b) hair as an inert, chemically
homogeneous substance which does not degrade biologically, (c) high
of substance, (d) record of both past and present exposure, and (e)
and noninvasive (Bland, 1984, p. 27).
Psychological symptoms evident with mineral toxicity. Each of the above minerals has biochemical effects on organic systems and processes. Aluminum toxicity results in dementia, Alzheimer’s-like symptoms (i.e., memory loss, neurological impairment), and parathyroid dysfunction (Bland, 1984, p. 49). These symptoms could easily be misdiagnosed as symptoms meeting criteria for psychological disorders. Mercury toxicity results in symptoms such as depression, irritability, memory dysfunction, and inability to concentrate (Bland, 1984, p. 48) which also mimics psychological disorders, promoting misdiagnosis. Abnormal calcium levels may be exhibited through aggression, anxiety, hyperactivity, bipolar-like symptoms, and depression. Abnormal cobalt levels could be exhibited by aggressive behavior or learning disorders. Abnormal iron levels could be exhibited by aggressive behavior, alcoholism, ADHD-like symptoms, dementia, depression, fatigue, insomnia, learning disorders, or schizophrenia. Abnormal manganese levels may be evident in aggression, alcoholism, hyperactivity, dementia, learning disorders, or schizophrenia. Abnormal phosphorus levels may be exhibited through alcoholism, anxiety, ADHD-like symptoms, or dementia. Lead toxicity may be demonstrated by aggressive behavior, ADHD-like symptoms, chronic fatigue, dementia, depression, learning disorders, or schizophrenia. Abnormal levels of zinc may be evident by aggressive behavior, alcoholism, ADHD-like symptoms, chronic fatigue, dementia, depression, eating disorders, insomnia, and learning disorders. Any of these mineral deficiencies or toxicities could result in diagnosis of a psychological disorder rather than recognition and correction of the underlying physiological cause.
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