Immunological investigations of the cerebrospinal fluid in patients with recent onset psychotic disorders: A study protocol

BACKGROUND

Though many previous studies have indicated immunological alterations in psychotic disorders, the role and prevalence of neuroinflammation is still unknown. Studies previously investigating immune related biomarkers in the cerebrospinal fluid (CSF) of these patients are mainly small studies on few markers, and many have not compared patients to healthy controls.

METHODS

We will conduct a large case-control study including at least 100 patients with recent onset psychotic disorders and 100 sex- and age matched healthy controls. The cases will include patients diagnosed with a psychotic disorder according to ICD-10 (F20/F22-29) within a year prior to inclusion. We will collect both CSF, blood and fecal samples, to gain insight into possible immunological alterations. The psychopathology of all participants will thoroughly be evaluated using the SCAN interview, and multiple rating scales covering different symptom groups. All participants will partake in a detailed neurological examination, including the Neurological Evaluation Scale assessing neurological soft signs. Additionally, we will assess cognitive functioning, evaluate quality of life and level of functioning, and collect data on a broad array of possible confounders. Our primary outcomes will include CSF leucocytes, CSF/serum albumin ratio, CSF total protein, IgG index, CSF levels of IL-6 and IL-8, and presence of antineuronal autoantibodies in CSF and blood. For our secondary outcomes, exploratory analyses will be performed on a broader panel of neuroimmunological markers. All participants will be invited for a follow-up visit to assess longitudinal changes. The current study is part of a larger CSF biobank build-up for severe mental disorders (PSYCH-FLAME).

DISCUSSION

This study will represent the largest investigation of CSF in patients with psychotic disorders compared to healthy controls to date. We expect the study to contribute with new, important knowledge on pathophysiological mechanisms, and to help pave the way for future investigations of individualized treatment options.

TRIAL REGISTRATION

The study is approved by The Regional Committee on Health Research Ethics (Capital Region, j.no: H-16030985) and The Danish Data Protection Agency (j.no: RHP-2016-020, I-Suite no.: 04945).

Cytokines in cerebrospinal fluid of patients with schizophrenia spectrum disorders: New data and an updated meta-analysis

Few studies have been conducted examining cytokines in cerebrospinal fluid of patients compared to healthy volunteers. The goals of this study were: 1) to report original data detailing cytokine levels in the cerebrospinal fluid (CSF) of 10 patients with a schizophrenia spectrum disorder (SSD) diagnosis and 10 healthy controls and 2) to conduct a meta-analysis of the available data on cytokine levels in the CSF of patients with SSD compared to healthy controls, including our new data. Cytokine concentrations were measured using the Q-plex Human Cytokine Screen array in CSF of 10 patients with SSD and 10 healthy volunteers. For the meta-analysis, an electronic PubMed and Google Scholar search without restrictions was conducted for articles that reported on cytokine levels in CSF in patients with an SSD compared to healthy controls. Our original data revealed statistically significant increases in levels of interleukin-8 (IL-8) and interleukin-1 beta (IL-1β) in the CSF of patients with an SSD compared to healthy volunteers. Our meta-analysis showed statistically significant increases in interleukin-6 (IL-6) and IL-8 in patients compared to healthy volunteers. Effect sizes between treated and untreated patients for IL-6 were of similar magnitude. However, IL-6 levels were higher in early stage schizophrenia patients compared to chronic schizophrenia patients. Studies with larger sample sizes, comprehensive assessments and ideally in the context of a randomized controlled intervention to minimize the impact of confounding factors are needed to fully understand the role of cytokines and inflammatory markers in the pathophysiology and treatment of schizophrenia.

Structural magnetic resonance imaging in patients with first-episode schizophrenia, psychotic and severe non-psychotic depression and healthy controls

Background

Structural brain abnormalities are prevalent in patients with schizophrenia and affective disorders.

Aims

To study how regional brain volumes and their ratios differ between patients with schizophrenia, psychotic depression, severe non-psychotic depression and healthy controls.

Method

Magnetic resonance imaging scans of the brain on first-episode patients and on healthy controls.

Results

Patients with schizophrenia had a smaller left frontal grey matter volume than the other three groups. Patients with psychotic depression had larger ventricular and posterior sulcal cerebrospinal fluid (CSF) volumes than controls. Patients with depression had larger white matter volumes than the other patients.

Conclusions

Left frontal lobe, especially its grey matter volume, seems to be specifically reduced in first-episode schizophrenia. Enlarged cerebral ventricles and sulcal CSF volumes are prevalent in psychotic depression. Preserved or expanded white matter is typical of non-psychotic depression.

Gender effects on brain changes in early-onset psychosis

Progressive loss of cortical gray matter (GM) and increase of cerebrospinal fluid (CSF) have been reported in early-onset psychosis (EOP). EOP typically begins during adolescence, a time when developmental brain trajectories differ by gender. This study aimed to determine gender differences in progression of brain changes in this population. A sample of 61 (21 females) adolescents with a first psychotic episode and a matched sample of 70 (23 females) controls underwent both baseline and 2-year follow-up anatomical brain imaging assessments. Regional GM and CSF volumes were obtained using automated methods based on the Talairach's proportional grid system. At baseline, only male patients showed a clear pattern of alterations in the frontal lobe relative to controls (smaller GM and larger CSF volumes). However, parallel longitudinal changes for male and female patients relative to controls were observed, resulting in a common pattern of brain changes across both genders: rate of left frontal lobe GM volume loss was larger in male (-3.8%) and female patients (-4.2%) than in controls (-0.7% males; -0.4% females). The reverse was found for the CSF volume in the left frontal lobe. While the GM and CSF volumes of females with EOP appear to be within the normal range at initial illness onset, our results point to a similar trajectory of increased/accelerated brain changes in both male and female patients with EOP. The pattern of progression of brain changes in psychosis appears to be independent of gender or structural alterations on appearance of psychotic symptoms.

Low-activity allele of Catechol-O-Methyltransferase (COMTL) is associated with increased lateral ventricles in patients with first episode non-affective psychosis

BACKGROUND

Structural brain anomalies are present at early phases of psychosis. The objective was to examine the impact of Catechol-O-Methyltransferase (COMT) gene variations on brain morphology in first-episode non-affective psychosis. We hypothesized that the low activity-COMT (COMT(L)) allele would be associated with the presence of structural brain changes as assessed by quantitative magnetic resonance imaging (MRI).

METHODS

Fifty-two males and 23 females underwent COMT genotyping and MRI. Patients were categorized into three genetic subgroups: COMT(H/H), COMT(L/H) and COMT(L/L). MRI data were analyzed using BRAINS2. Global and lobar volumes of grey matter (GM) and cerebrospinal fluid (CSF) were compared among the three groups after controlling for total intracranial volume and age of illness onset.

RESULTS

COMT(L) carriers showed a significant enlargement of the lateral ventricles (F = 7.13, p = 0.009), right lateral ventricle (F = 5.99, p = 0.017) and left lateral ventricle (F = 6.22, p = 0.015). No other significant differences in any of the brain structures were found among subgroups.

CONCLUSIONS

Our findings suggest that genetic variations of COMT can contribute to the enlargement of the lateral ventricles described in early phases of non-affective psychosis.

Antiphospholipid antibodies in blood and cerebrospinal fluids of patients with psychosis

Antiphospholipid antibodies (aPL) have been reported in the cerebrospinal fluids (CSF) of neurology patients but no CSF studies with psychiatric patients exist. We tested serum from 100 hospitalized psychotic patients having hallucinations and/or delusions for aPL. Patients with positive serum aPL findings were asked to submit CSF for aPL testing. Five CSF samples had aPL specificities not found in the patient's serum suggesting the possibility of intrathecal synthesis. Specificity and isotype discordance between CSF and blood aPL in these psychiatric patients implicates a central nervous system independent autoimmune process that may have an underlying association with the pathophysiology of their diseases.

Anandamide levels in cerebrospinal fluid of first-episode schizophrenic patients: impact of cannabis use

BACKGROUND

Previous studies have shown that cerebrospinal fluid (CSF) from schizophrenic patients contains significantly higher levels of the endogenous cannabinoid anandamide than does CSF from healthy volunteers. Moreover, CSF anandamide levels correlated inversely with psychotic symptoms, suggesting that anandamide release in the central nervous system (CNS) may serve as an adaptive mechanism countering neurotransmitter abnormalities in acute psychoses. In the present study we examined whether cannabis use may alter such a mechanism.

METHODS

We used liquid chromatography/mass spectrometry (LC/MS) to measure anandamide levels in serum and CSF from first-episode, antipsychotic-naïve schizophrenics (n=47) and healthy volunteers (n=81). Based on reported patterns of cannabis use and urine delta9-tetrahydrocannabinol (delta9-THC) tests, each subject group was further divided into two subgroups: 'low-frequency' and 'high-frequency' cannabis users (lifetime use < or = 5 times and > 20 times, respectively). Serum delta9-THC was investigated to determine acute use and three patients were excluded from the analysis due to detectable delta9-THC levels in serum.

RESULTS

Schizophrenic low-frequency cannabis users (n=25) exhibited > 10-fold higher CSF anandamide levels than did schizophrenic high-frequency users (n=19, p=0.008), healthy low-frequency (n=55, p<0.001) or high-frequency users (n=26, p<0.001). In contrast, no significant differences in serum anandamide levels were found among the four subgroups. CSF anandamide levels and disease symptoms were negatively correlated in both user groups.

CONCLUSIONS

The results indicate that frequent cannabis exposure may down-regulate anandamide signaling in the CNS of schizophrenic patients, but not of healthy individuals. Thus, our findings suggest that alterations in endocannabinoid signaling might be an important component of the mechanism through which cannabis impacts mental health.

Acute psychotic symptoms in HIV-1 infected patients are associated with increased levels of kynurenic acid in cerebrospinal fluid

Human immunodeficiency virus type 1 (HIV-1) infection is associated with psychiatric complications including cognitive impairment, affective disorders, and psychosis. Previous studies have revealed a disturbed kynurenine metabolism in these patients leading to increased levels of neuroactive compounds acting at glutamatergic neurotransmission. Kynurenic acid (KYNA), one of these metabolites is a glutamate-receptor antagonist, preferentially blocking the glycine site of the N-methyl-d-aspartate (NMDA) receptor. Increased levels of brain KYNA have been suggested to induce a NMDA receptor hypofunction that is associated with psychotic symptoms. In the present study, we analyze the concentration of KYNA in the cerebrospinal fluid (CSF) from HIV-1 infected patients (n=22), including HIV-1 infected patients with psychotic symptoms (n=8) and HIV-1 infected patients without psychiatric symptoms (n=14). We found that HIV-1 infected patients had significantly higher median concentration of CSF KYNA (3.02nM) compared to healthy controls (1.17nM). Furthermore, CSF KYNA levels were significantly elevated in HIV-1 infected patients with psychotic symptoms (4.54nM) compared to patients with HIV-1 without psychiatric symptoms (2.28nM). Present results indicate that increased levels of CSF KYNA may be associated with development of psychotic symptoms in HIV-1 infected patients.

Disease biomarkers in cerebrospinal fluid of patients with first-onset psychosis

BACKGROUND

Psychosis is a severe mental condition that is characterized by a loss of contact with reality and is typically associated with hallucinations and delusional beliefs. There are numerous psychiatric conditions that present with psychotic symptoms, most importantly schizophrenia, bipolar affective disorder, and some forms of severe depression referred to as psychotic depression. The pathological mechanisms resulting in psychotic symptoms are not understood, nor is it understood whether the various psychotic illnesses are the result of similar biochemical disturbances. The identification of biological markers (so-called biomarkers) of psychosis is a fundamental step towards a better understanding of the pathogenesis of psychosis and holds the potential for more objective testing methods.

METHODS AND FINDINGS

Surface-enhanced laser desorption ionization mass spectrometry was employed to profile proteins and peptides in a total of 179 cerebrospinal fluid samples (58 schizophrenia patients, 16 patients with depression, five patients with obsessive-compulsive disorder, ten patients with Alzheimer disease, and 90 controls). Our results show a highly significant differential distribution of samples from healthy volunteers away from drug-naïve patients with first-onset paranoid schizophrenia. The key alterations were the up-regulation of a 40-amino acid VGF-derived peptide, the down-regulation of transthyretin at approximately 4 kDa, and a peptide cluster at approximately 6,800-7,300 Da (which is likely to be influenced by the doubly charged ions of the transthyretin protein cluster). These schizophrenia-specific protein/peptide changes were replicated in an independent sample set. Both experiments achieved a specificity of 95% and a sensitivity of 80% or 88% in the initial study and in a subsequent validation study, respectively.

CONCLUSIONS

Our results suggest that the application of modern proteomics techniques, particularly mass spectrometric approaches, holds the potential to advance the understanding of the biochemical basis of psychiatric disorders and may in turn allow for the development of diagnostics and improved therapeutics. Further studies are required to validate the clinical effectiveness and disease specificity of the identified biomarkers.

Relationship of white matter hyperintensities to cerebrospinal fluid glucose polyol pathway metabolites-a pilot study in treatment-resistant affective disorder patients

BACKGROUND

Magnetic resonance imaging (MRI) white matter hyperintensities (WMHs) are found at higher rates in patients with affective disorders, particularly late-life or treatment-resistant disorders. Studies support a vascular pathogenesis for WMHs in late-life onset disorders; however, pathogenesis in typical early-life onset disorders is less clear. Based on associations between diabetes mellitus and both WMHs and affective disorders, this study investigated the relationship between WMHs and brain glucose metabolism by the polyol pathway-a pathway linked to nervous tissue disease in diabetes.

METHODS

Burdens of fluid-attenuated inversion recovery (FLAIR) WMHs were quantified and correlated with cerebrospinal fluid (CSF) concentrations of glucose metabolites in 10 nondiabetic inpatients with treatment-resistant bipolar, unipolar, and schizoaffective disorders and 10 nondiabetic control patients who had been investigated clinically for transient neurological symptoms.

RESULTS

Deep but not periventricular WMH burden correlated positively and significantly with elevated CSF concentrations of sorbitol, the specific polyol pathway metabolite of glucose (rho=0.86, p=0.002), in the affective disorders but not the control group.

LIMITATIONS

This was a pilot study with a relatively small number of subjects; therefore, conclusions are tentative. Controls were not healthy subjects; they were patients with transient neurological symptoms.

CONCLUSIONS

This is the first reported evidence of a relationship between WMHs and increased brain glucose metabolism by the polyol pathway in patients with affective disorders. More extensive studies are necessary to determine whether this preliminary finding represents a pathogenetic relationship.

Cerebrospinal anandamide levels are elevated in acute schizophrenia and are inversely correlated with psychotic symptoms

The endocannabinoids are a family of bioactive lipids that activate CB1 cannabinoid receptors in the brain and exert intense emotional and cognitive effects. Here, we have examined the role of endocannabinoid signaling in psychotic states by measuring levels of the endocannabinoid anandamide in cerebrospinal fluid (CSF) of acute paranoid-type schizophrenic patients. We found that CSF anandamide levels are eight-fold higher in antipsychotic-naive first-episode paranoid schizophrenics (n = 47) than healthy controls (n = 84), dementia patients (n = 13) or affective disorder patients (n = 22). Such an alteration is absent in schizophrenics treated with 'typical' antipsychotics (n = 37), which antagonize dopamine D2-like receptors, but not in those treated with 'atypical' antipsychotics (n = 34), which preferentially antagonize 5HT(2A) receptors. Furthermore, we found that, in nonmedicated acute schizophrenics, CSF anandamide is negatively correlated with psychotic symptoms (rS = -0.452, P = 0.001). The results suggest that anandamide elevation in acute paranoid schizophrenia may reflect a compensatory adaptation to the disease state.

Intrathecal levels of matrix metalloproteinases in systemic lupus erythematosus with central nervous system engagement

Symptoms originating from the central nervous system (CNS) occur frequently in patients with systemic lupus erythematosus (SLE), and CNS involvement in lupus is associated with increased morbidity and mortality. We recently showed that neurones and astrocytes are continuously damaged during the course of CNS lupus. The matrix metalloproteinases (MMPs) are a group of tissue degrading enzymes that may be involved in this ongoing brain destruction. The aim of this study was to examine endogenous levels of free, enzymatically active MMP-2 and MMP-9 in cerebrospinal fluid from patients with SLE. A total of 123 patients with SLE were evaluated clinically, with magnetic resonance imaging of brain and cerebrospinal fluid (CSF) analyses. Levels of free MMP-2 and MMP-9 were determined in CSF using an enzymatic activity assay. CSF samples from another 22 cerebrally healthy individuals were used as a control. Intrathecal MMP-9 levels were significantly increased in patients with neuropsychiatric SLE as compared with SLE patients without CNS involvement (P < 0.05) and healthy control individuals (P = 0.0012). Interestingly, significant correlations between MMP-9 and intrathecal levels of neuronal and glial degradation products were noted, indicating ongoing intrathecal degeneration in the brains of lupus patients expressing MMP-9. In addition, intrathecal levels of IL-6 and IL-8--two cytokines that are known to upregulate MMP-9--both exhibited significant correlation with MMP-9 levels in CSF (P < 0.0001), suggesting a potential MMP-9 activation pathway. Our findings suggest that proinflammatory cytokine induced MMP-9 production leads to brain damage in patients with CNS lupus.

CSF-methionine is elevated in psychotic patients

Cerebrospinal fluid levels of methionine (MET), homocysteine (HCY) and cystathionine were studied in patients with psychotic disorders (n=36) and in healthy controls (n=25). Patients had significantly higher MET than controls (p<0.00001), and ten of the patients had MET levels above anyone of the controls. Moreover, three young male patients had HCY levels highly above any of the controls. There were no significant gender differences in any of the parameters. Neither ageing nor neuroleptic treatment offered an explanation for the increase of MET, because also young and drug-naive patients had significantly higher MET than the controls. We conclude that patients with psychotic disorders, at least in a phase of acute exacerbation, are often in a state of disturbed one-carbon metabolism.

Corticotropin-releasing factor in posttraumatic stress disorder (PTSD) with secondary psychotic symptoms, nonpsychotic PTSD, and healthy control subjects

BACKGROUND

Recent studies have reported a high comorbidity between posttraumatic stress disorder (PTSD) and psychotic symptoms, and it has been hypothesized that PTSD with comorbid psychosis is a severe form of PTSD. Few studies have examined the neurobiology of PTSD with comorbid psychosis. If PTSD with secondary psychotic symptoms (PTSD-SP) is a severe form of PTSD, then it might be expected to show more extreme perturbations in the neuroendocrine patterns that characterize PTSD.

METHODS

Patients with PTSD with secondary psychotic symptoms (PTSD-SP), PTSD without psychosis, and healthy comparison subjects were compared for differences in cerebrospinal fluid concentrations of corticotropin-releasing factor (CRF) and somatotropin-release-inhibiting hormone (SRIF).

RESULTS

The PTSD-SP subjects had significantly higher mean levels of CRF than either the PTSD or control subjects (p <.01). The three groups showed similar SRIF levels.

CONCLUSIONS

These data implicate abnormalities in the secretion of CRF with the production of secondary psychotic symptoms in PTSD. This finding supports the validity of PTSD-SP as a PTSD subtype and as a severe form of PTSD.

[Cerebrospinal fluid filtration as experimental therapy in therapy refractory psychoses in Borna disease virus seropositive patients. Therapeutic effects, findings]

According to previous investigations, mild Borna disease virus encephalitis may underlie a subgroup of affective or schizophrenic type psychoses. And virus-induced immune pathology may underlie even a larger subgroup of psychoses. We treated BDV seropositive patients suffering from therapy resistant schizophrenic or affective spectrum psychoses by cerebrospinal fluid filtration (CSFF) in an experimental add-on treatment. CSFF was shown previously to be an effective immune modulatory treatment in autoimmune neurological disease, Guillain-Barré syndrome. CSFF appears to be an effective treatment in therapy resistant psychosis also, but only 4 patients were treated yet.

Searching for a structural endophenotype in psychosis using computational morphometry

Structural cerebral abnormalities are frequently observed in schizophrenia. These abnormalities may indicate vulnerability for the disorder, as evidenced by reports of familial clustering of measures identified through region-of-interest analyses using manual outlining procedures. We used computational morphometry to detect structural differences within the entire brain to further examine possible structural endophenotypes. Magnetic resonance imaging scans were obtained in 31 psychotic patients, 32 non-psychotic first-degree relatives of psychotic patients and 27 healthy controls. The images were processed using an automated procedure, yielding global grey matter, white matter, CSF and total brain volume. The relative distribution of grey matter was compared between groups on a clustered-voxel basis. Global grey matter and total brain volume did not differ between the groups. White matter volume was significantly higher and CSF volume significantly lower in relatives compared to both cases and controls. The clustered-voxel based group comparison yielded evidence for significant grey matter deficits in fronto-thalamic-cerebellar regions, in psychotic patients, whereas the most prominent deficits in relatives involved the cerebellum. Patients with psychosis and first-degree healthy relatives of patients with psychosis show cerebellar abnormalities, which may constitute a marker of genetic transmission.

Cerebral tissue alterations and daily life stress experience in psychosis

OBJECTIVE

To examine whether the total volumes of cerebrospinal fluid (CSF), cerebral grey matter and white matter were correlated with the experience of environmental stress in daily life situations.

METHOD

Twenty-seven patients with psychosis underwent magnetic resonance imaging scanning and a random time-sampling self-assessment technique (Experience Sampling Method) to determine subjective daily life stress experiences. Total cerebral tissue volumes were derived from an automated segmentation procedure.

RESULTS

CSF volume was positively associated with daily life event-related stress (beta=0.016, P=0.002), while the association with total white matter was negative (beta=-0.013, P=0.005). The effects were independent of each other and of total cerebral volume and other confounders. No large or significant association was found with grey matter volume.

CONCLUSION

Subjective stress experience in daily life is associated with increased CSF and reduced white matter volumes in patients with psychosis, suggesting functional significance of these cerebral measures.

[Hashimoto encephalopathy. Analysis of four case reports]

INTRODUCTION

Encephalopathy associated with Hashimoto's thyroiditis has been recognized for more than 30 years and is probably underestimated.

EXEGESIS

We report four patients with Hashimoto's thyroiditis who presented neurological or psychiatric features. There were three women and one man, with a mean age of 68 years. Neurological presentations were various: seizures, psychotic episodes, altered consciousness, hallucinations without usual aetiological diseases (infectious, metabolic, neoplasic, vascular, etc.). Neurological investigations (EEG, brain CT, magnetic resonance imaging) were unspecific. In all cases, a moderately high CSF protein level without pleocytosis was found. Patients presented slight hypothyroidism with high titers of antithyroperoxidase antibodies. Despite hormone therapy replacement, neurological features persisted. Outcome was favorable under steroid therapy.

CONCLUSION

Hashimoto's encephalopathy must be considered in the face of neuropsychiatric manifestations without obvious etiology. Pathogenic mechanisms are not clear but probably involve autoimmune cerebral vasculitis because of the efficacy of steroids.

CSF GABA in psychotic disorders

CSF GABA levels were not significantly different in a group of drug-free psychotic patients compared to a group of psychotic patients at two points during haloperidol treatment or a neurological comparison group. In the untreated group, CSF GABA was significantly negatively correlated with clinical ratings of anxiety and agitation. Early in haloperidol treatment CSF GABA was significantly positively correlated with CSF HVA.

Current antipsychotic dose correlates to mononuclear cell counts in the cerebrospinal fluid of psychotic patients

Elevated cerebrospinal fluid (CSF) angiotensin I-converting enzyme (ACE) levels have been evidenced in patients with schizophrenia who have been treated with antipsychotics. In order to explore a possible mononuclear cell origin of CSF ACE, the authors determined CSF ACE and CSF mononuclear cell counts from 25 acutely psychotic patients, who had been drug-free for at least 4 months but started on conventional antipsychotic medication within a few days before sampling. No correlations were found between CSF to serum ACE ratio and CSF mononuclear cell counts. However, CSF total mononuclear cell count, CSF lymphocyte count, and CSF mononuclear phagocyte count evidenced significant positive correlations with current dose of antipsychotic medication expressed as chlorpromazine equivalents. The authors conclude that no indication of a relationship between mononuclear cells and CSF ACE activity was found. Surprisingly, a relationship between chlorpromazine dose and CSF mononuclear cell counts was found, which may indicate drug-related changes in cell-mediated immunity. This finding needs replication and further corroboration in well-designed studies.

Cerebrospinal fluid glutamate inversely correlates with positive symptom severity in unmedicated male schizophrenic/schizoaffective patients

BACKGROUND

Recent hypotheses have suggested that diminished brain glutamate may be of importance in the neurochemical basis of schizophrenia.

METHODS

We assayed cerebrospinal fluid for glutamate and obtained clinical symptom ratings in 19 medication-free (except p.r.n. chloral hydrate) schizophrenic or schizoaffective (typically with significant schizophrenic qualities) male inpatients.

RESULTS

Ratings of positive symptoms were significantly inversely correlated (rs = -.457, p < .05, one-tailed test) with glutamate concentrations. Hallucinatory behavior was strongly correlated (rs = -.621, p < .01, one-tailed test) with glutamate. A subset of 11 patients consented to a second lumbar puncture (LP) after treatment with haloperidol (typically 15 or 20 mg/day) for 2-4 weeks. Haloperidol treatment did not alter glutamate concentrations. No correlations were noted between glutamate and symptoms in the medicated subsample. Though approximately half the patients received chloral hydrate during the 72 hours prior to the unmedicated LP, the correlations between positive symptoms and glutamate in the patients who received no chloral hydrate prior to the LP were quite similar to those found in the overall sample.

CONCLUSIONS

The results provide further support for the potential importance of glutamate in the neurochemical basis of schizophrenia.

Regional gray matter, white matter, and cerebrospinal fluid distributions in schizophrenic patients, their siblings, and controls

BACKGROUND

Cortical gray matter volume reductions and cerebrospinal fluid (CSF) volume increases are robust correlates of schizophrenia, but their sources have not been established conclusively.

METHODS

Structured diagnostic interviews and magnetic resonance imaging scans of the brain were obtained on 75 psychotic probands (63 with schizophrenia and 12 with schizoaffective disorder), ascertained so as to be representative of all such probands in a Helsinki, Finland, birth cohort; 60 of their nonpsychotic full siblings; and 56 demographically similar control subjects without a personal or family history of treated psychiatric morbidity.

RESULTS

Patients with schizophrenia and their siblings exhibited significant reductions in cortical gray matter volume and significant increases in sulcal CSF volume compared with controls. The patients, but not their siblings, also exhibited significant reductions in white matter volume and significant increases in ventricular CSF volume. Regional effects were most robust when component volumes were expressed as percentages of overall regional volumes; in this case, for patient and sibling groups, gray matter volume reductions and sulcal CSF volume increases were significantly more pronounced in the frontal and temporal lobes than in the remainder of the brain. None of the group differences varied significantly by sex or hemisphere.

CONCLUSIONS

Structural alterations of the cerebral cortex, particularly in the frontal and temporal lobes, are present in patients with schizophrenia and in some of their siblings without schizophrenia; such changes are thus likely to reflect genetic (or shared environmental) effects. Ventricular enlargement is unique to the clinical phenotype and is thus likely to be affected primarily by nonshared causative factors.

Differential roles of the anti-ribosomal P antibody and antineuronal antibody in the pathogenesis of central nervous system involvement in systemic lupus erythematosus

OBJECTIVE

To compare the role of antibodies against the ribosomal P protein (anti-P) with that of antibodies against neuronal cells (anti-N) in the pathogenesis of central nervous system (CNS) involvement in systemic lupus erythematosus (SLE).

METHODS

Sera from 87 SLE patients (27 with non-CNS SLE, 34 with lupus psychosis, and 26 with nonpsychotic CNS lupus) and from 20 control patients with neurologic manifestations without SLE and cerebrospinal fluid (CSF) from 41 patients with CNS lupus and from the 20 control patients were assayed for IgG anti-P and anti-N by an enzyme-linked immunosorbent assay (ELISA) using ribosomal P synthetic peptides and by a cell ELISA using paraformaldehyde-fixed SK-N-MC neuroblastoma cell lines, respectively.

RESULTS

Serum anti-P levels were significantly elevated in patients with lupus psychosis compared with those with non-CNS SLE or those with nonpsychotic CNS lupus, whereas there were no significant differences in serum anti-N levels among these 3 groups. In contrast, CSF anti-N levels were significantly elevated in patients with lupus psychosis compared with those with nonpsychotic CNS lupus and compared with non-SLE controls, whereas CSF anti-P were not detected in most of the patients.

CONCLUSION

The results indicate that anti-P in the systemic circulation and anti-N in the CSF are involved in the development of lupus psychosis.

CSF neurotensin concentrations and antipsychotic treatment in schizophrenia and schizoaffective disorder

OBJECTIVE

The relationship between CSF neurotensin concentrations and measures of psychopathology in patients with schizophrenia or schizoaffective disorder was examined before and after treatment with antipsychotic drugs.

METHOD

CSF neurotensin concentrations were measured in 42 drug-free patients with schizophrenia or schizoaffective disorder. For 18 of these patients, CSF neurotensin was measure again after 4 weeks of antipsychotic treatment.

RESULTS

Significantly higher levels of pretreatment psychopathology were observed in the patients with the lowest CSF neurotensin concentrations. Furthermore, improvements in overall psychopathology and, particularly, negative symptoms were correlated with increases in CSF neurotensin concentrations during treatment.

CONCLUSIONS

These findings provide further evidence for a role of neurotensin the pathophysiology of psychosis and in the mechanism of action of antipsychotic drugs.

Schizophrenia, psychosis, and cerebral spinal fluid homovanillic acid concentrations

Neuroleptic drugs block brain dopamine receptors and are effective in treating psychoses of diverse origins. This finding has become a cornerstone of the dopamine theory of schizophrenia, but clinical studies relating schizophrenia, per se, to brain dopamine metabolism have ranged from controversial to negative. This article presents new evidence that cerebrospinal fluid levels of the dopamine metabolite homovanillic acid are related to the severity of psychosis in schizophrenia. These results support the concept that homovanillic acid levels in cerebrospinal fluid vary as a function of psychosis rather than being related to the diagnosis of schizophrenia per se.

Association of anti-ribosomal P protein antibodies with neuropsychiatric systemic lupus erythematosus

OBJECTIVE

Although it has been reported that anti-ribosomal P protein antibodies (anti-P) are highly specific for lupus psychosis, there have been discrepancies among the studies regarding the clinical correlation of these antibodies with systemic lupus erythematosus (SLE). The present study was therefore carried out to reappraise the association of anti-P and neuropsychiatric SLE.

METHODS

Highly purified synthetic ribosomal P peptides of the carboxyl-terminal 22-amino acid sequence were conjugated to human serum albumin (HSA) with the use of glutaraldehyde. Anti-P in sera from 75 patients with SLE (26 without central nervous system disease [non-CNS], 28 with lupus psychosis, and 21 with nonpsychotic CNS involvement [nonpsychotic CNS lupus]) were analyzed with an enzyme-linked immunosorbent assay (ELISA), using HSA-ribosomal P peptide conjugates as antigens. Anti-P levels were quantitated by subtracting the nonspecific binding activities to HSA.

RESULTS

The ELISA was found to be specific for anti-P, as determined by comparison with the results of Western blotting using extracts of HEp-2 cells. Serum anti-P levels were significantly elevated in patients with lupus psychosis, including organic brain syndrome and nonorganic psychosis, compared with those with non-CNS SLE or those with nonpsychotic CNS lupus. There were no significant differences in serum anti-P levels between patients with organic brain syndrome and those with nonorganic psychosis. Anti-P antibodies were not detected in the cerebrospinal fluid of patients with either lupus psychosis or nonpsychotic CNS lupus.

CONCLUSION

Our results, obtained from the highly specific ELISA using HSA-ribosomal P peptide conjugates, confirm the correlation of serum anti-P with lupus psychosis. The data also suggest that differences in the purity of the ribosomal P peptides used might be a major reason for the conflicting results in the literature regarding the association of anti-P with lupus psychosis.

Classification of CSF samples from normal and post-partum psychotic women using chromatographic profiles with bilinear projections: a multivariate approach

This paper demonstrates how chromatographic profiles of cerebrospinal fluid (CSF) have been subjected to multivariate data analysis to discriminate between CSF samples from women with post-partum psychosis and those from healthy women. Instead of peak-heights or areas, digitally defined chromatographic profiles were examined using principal component analysis (PCA). In accordance with the diagnosis, we have found a complex profile pattern of at least ten composite peaks that discriminates between these groups. Two of these peaks were for the discrimination particularly clearly between the two groups. We speculate that these findings can be useful in the diagnosis of post-partum psychosis, increasing diagnostic precision and having both clinical and prognostic implications.

Elevation of CSF somatostatin concentrations in mania

OBJECTIVE

The aim of this study was to compare levels of CSF somatostatin (somatotropin release-inhibiting factor) in drug-free patients with different major psychiatric disorders.

METHOD

CSF somatostatin concentrations were measured in 66 drug-free inpatients with Research Diagnostic Criteria diagnoses of schizophrenia, major depressive disorder, manic disorder, or schizoaffective disorder.

RESULTS

In comparison with both the patients with schizophrenia and the patients with schizoaffective disorder, the manic patients had markedly elevated CSF somatostatin concentrations. The depressed patients had significantly higher levels than the schizophrenic patients.

CONCLUSIONS

Mania is associated with relatively higher CSF somatostatin concentrations.

Cerebrospinal fluid somatostatin concentrations in schizophrenia and schizoaffective disorder: the effects of antipsychotic treatment

The authors examined the effects of antipsychotic treatment on cerebrospinal fluid somatostatin like immunoreactivity (CSF SLI) in 14 schizophrenic and 3 schizoaffective patients. There was a modest but significant increase in CSF SLI in 13 out of the 14 schizophrenic patients. In addition, there was a significant positive correlation between duration of treatment and post-treatment CSF SLI concentrations. No differential response was noted in patients also treated with the anticholinergic benztropine.

Case report: psychosis associated with hepatitis B

An acute disintegrative disorder in a child with acute hepatitis B virus (HBV) infection is described. Both hepatitis B surface antigen (HBsAg) and HBV-DNA were detected in cerebrospinal fluid (CSF) by means of enzyme-linked immunosorbent assay (ELISA) and the polymerase chain reaction (PCR) technique respectively. A markedly elevated level of CSF adenylate kinase (AK), which normalised as the patient recovered spontaneously, suggested an organic brain disorder. Demonstration of intra-blood-brain barrier production of IgG supported the possibility of local infection by HBV within the central nervous system.

CSF and plasma MHPG, and CSF MHPG index: pretreatment levels in diagnostic groups and response to somatic treatments

The authors report a significant positive correlation between levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) in cerebrospinal fluid (CSF) and plasma in drug-free affective disorder patients (major depression, mania, and schizoaffective disorder), but not in schizophrenia. Recent kinetic studies on the relationship between plasma and CSF MHPG discourage the interpretation of independent CSF MHPG levels without correction for the diffusion of MHPG across the blood-brain barrier. The authors therefore examine pretreatment CSF and plasma MHPG levels, and the CSF MHPG index (CSF MHPG corrected for by using simultaneously obtained plasma MHPG according to the method of Kopin et al. [1983]). No significant differences were found in these pretreatment MHPG measures among the four diagnostic groups. Changes in these MHPG indices, and their correlations with behavioral rating scores, are also examined with respect to response to the four major somatic therapies (neuroleptics, lithium, antidepressants, and electroconvulsive therapy).

CSF 5-HIAA predicts suicide risk after attempted suicide

Suicide risk after attempted suicide, as predicted by cerebrospinal fluid (CSF) monoamine metabolite concentrations, was studied in a sample of 92 psychiatric mood disorder inpatients admitted shortly after attempting suicide. The potential of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the CSF to predict suicide risk within the first year after attempted suicide was studied by means of survival analysis after after median split subgrouping. Eleven patients (12%) committed suicide within 1 year after attempted suicide. Eight of these belonged to the below-the-median (< 87 nM) CSF 5-HIAA subgroup, that is, the suicide risk was 17% as compared with 7% among those with above-the-median CSF 5-HIAA. The cumulative number of survived patient-months during the first year after attempted suicide was significantly lower in the low CSF 5-HIAA subgroup. It was concluded that low CSF 5-HIAA predicts short-range suicide risk after attempted suicide in mood disorder psychiatric inpatients. These findings lend further support to the serotonin hypothesis of suicide risk.

An association between low levels of 5-HIAA and HVA in cerebrospinal fluid and early mortality in a diagnostically mixed psychiatric sample

We followed up a sample of psychiatric patients (diagnoses predominantly schizophrenia and depression) who had participated in in-patient studies of their CSF over the past 15 years. The status of 73 former patients was confirmed, of whom 12 had died. Seven of these patients died at age < or = 40, largely of suicide, homicide, or accidental causes. These seven patients had significantly lower CSF 5-HIAA and HVA than living control patients. There were significant direct correlations between age at death and both CSF 5-HIAA and HVA in the deceased patients. The results offer support for CSF monoamine metabolites relating to early death in a diagnostically diverse sample of psychiatric patients.

Demonstration of immunoglobulin G with affinity for dopamine in cerebrospinal fluid from psychotic patients

Using an enzyme-linked immunosorbent assay, significantly raised concentrations of immunoglobulin G with affinity for the neurotransmitter dopamine were demonstrated in cerebrospinal fluid from psychotic patients. We have varied the antigen presentation in order to find a conjugate with low unspecific binding. The conjugation of dopamine to carbodiimide-activated poly-L-glutamic acid and that to activated succinimide ester of biotin are described. The use of glutaraldehyde conjugation is not recommended because of the risk of formation of tetrahydroisoquinolines. A strong correlation (r = 0.94, P < 0.001) between the results obtained with dopamine conjugated to poly-L-glutamic acid and dopamine conjugated to biotin was observed. Forty-two human cerebrospinal fluid samples from 20 psychotic patients, (12 with a bipolar disorder and 8 with schizophrenia) and 22 control patients, with various neurological diseases but no apparent psychiatric diseases were investigated. A significantly higher incidence (P < 0.001) of antibodies with affinity for dopamine were found in the group of psychotic patients compared with the neurological control group.

Effect of neuroleptic medication on cerebrospinal fluid monoamine metabolite concentrations in schizophrenia. Serotonin-dopamine interactions as a target for treatment

OBJECTIVE

This study examined the effect of neuroleptic treatment on indexes of dopamine and serotonin function in schizophrenic patients. We hypothesized that neuroleptic treatment would be effective by changing dopamine and serotonin function and/or by altering their interaction.

DESIGN

Lumbar cerebrospinal fluid (CSF) concentrations of the metabolites of dopamine (homovanillic acid, [HVA]) and serotonin (5-hydroxyindoleacetic acid, [5-HIAA]) were measured after a minimum drug-free period of two weeks and again after five weeks of treatment with haloperidol, 20 mg/d orally. Psychiatric symptoms were rated within one day of CSF sampling.

PATIENTS

Sixteen schizophrenic and three schizoaffective male inpatients.

RESULTS

Neuroleptic treatment significantly raised HVA concentrations and significantly increased the ratio between HVA and 5-HIAA. The increase in HVA was not related to symptomatic improvement, whereas the increase in the HVA/5-HIAA ratio was significantly correlated with reduction in overall symptomatology.

CONCLUSIONS

These findings suggest that the increase in HVA is relative to 5-HIAA, and not the absolute increase in HVA, that is related to symptomatic improvement. This, in turn, suggests that changing dopamine function relative to serotonin function, rather than changing dopamine per se, is associated with the therapeutic effect of haloperidol. Exploring serotonin-dopamine interactions in schizophrenia may be more informative than examining each system in isolation.

Analysis of cerebrospinal fluid from patients with psychiatric and neurological disorders by two-dimensional electrophoresis: identification of disease-associated polypeptides as fibrin fragments

Two-dimensional electrophoresis (2-DE) of cerebrospinal fluid (CSF) samples--from 347 patients with various psychiatric and neurological disorders--and subsequent silver staining revealed two additional polypeptides (Mr 40,000) in 49% of 111 schizophrenics, 46% of 43 schizoaffective patients, 36% of 41 patients with affective disorders, 43% of 28 patients with multiple sclerosis, but not in 25 patients without neurological symptomatology, nor in 9 patients with Lues, and in only 2 of 25 patients with AIDS. The two polypeptides, as detected by 2-DE, eluted after size exclusion chromatography in fractions containing proteins with Mr greater than 200,000. After 2-DE of CSF samples, enriched by gel chromatography, the polypeptides were immobilized by blotting onto glass-fiber membranes and subjected to N-terminal sequencing. Polypeptide A was identified as beta-chain remnant (beta 2), derived from plasmin cleavage of fibrin(ogen). After size exclusion chromatography, 2-DE, and Western blotting, polypeptide A and B, as well as several other spots, reacted with fibrinogen antibodies, suggesting that the polypeptides are subunits of a fibrin degradation complex.

Relation of CSF neurotensin concentrations to symptoms and drug response of psychotic patients

OBJECTIVE

The authors investigated the putative endogenous antipsychotic neurotensin in relation to both psychotic symptoms and patterns of response during treatment with an antipsychotic drug.

METHOD

Twenty recently admitted patients with mood-incongruent psychoses underwent 1) interviews with the Schedule for Affective Disorders and Schizophrenia for diagnostic evaluation and symptom profiles, 2) drug-free baseline measurements of CSF neurotensin and homovanillic acid, and 3) close monitoring of a therapeutic trial of haloperidol to determine latency of antipsychotic response.

RESULTS

A relative deficiency in CSF neurotensin was found in a subgroup of psychotic women whose clinical response to haloperidol was delayed for 11 to 35 days after initiation of the neuroleptic. These patients had greater thought disorder, delusions-hallucinations, behavioral disorganization, and impaired functioning than did psychotic patients with higher CSF concentrations of neurotensin. Neurotensin concentrations increased during treatment with haloperidol.

CONCLUSIONS

The study provides further evidence that there is diminished availability of neurotensin in some psychotic patients, with increases in neurotensin early in neuroleptic treatment. Exploration of neurotensin receptor agonists as a potentially novel class of antipsychotic compounds is suggested.

Characteristics of psychotic inpatients with high or low HVA levels at admission

OBJECTIVE

The purpose of this study was to examine the clinical profiles of psychotic patients whose fasting levels of plasma free homovanillic acid (HVA) were elevated on the day after admission to the hospital.

METHOD

These 85 subjects with nonorganic psychoses had been previously studied with respect to their response to neuroleptic treatment. They were divided into two groups on the basis of a median split of their pretreatment plasma HVA levels, and the two groups were compared on a number of clinical and demographic variables ascertained during their hospital stay. Fasting levels of plasma free HVA and 3-methoxy-4-hydroxyphenylglycol (MHPG) were measured by gas chromatography-mass spectrometry.

RESULTS

The high-HVA group tended to show a better prognostic profile than the low-HVA group; however, the only significant difference between groups was in the greater use of psychotogenic drugs by low-HVA males. Fourteen additional psychotic patients with distinctly elevated HVA levels and normal MHPG values were also diagnostically heterogeneous.

CONCLUSIONS

The results suggest that psychotic patients with different diagnoses who have relatively high levels of plasma free HVA before treatment will show a favorable early response to neuroleptic drugs. There may be neurobiological processes linking some patients across the clinical spectrum of the psychotic disorders.

Plasma norepinephrine in chronic schizophrenia

Several lines of evidence indicate altered noradrenergic function in schizophrenia. The authors examined resting, standing, and change (standing minus resting) in plasma norepinephrine levels in 14 drug-free patients with chronic schizophrenia or schizoaffective disorder and in 33 age- and sex-matched healthy volunteers. Schizophrenic patients had significantly higher resting and standing plasma norepinephrine levels and significantly greater change. Resting and standing levels were significantly related to positive and negative symptoms. There was a significant positive correlation between resting plasma and CSF norepinephrine levels and a significant negative correlation between CSF homovanillic acid and resting, standing, and change in plasma norepinephrine levels.

Intercorrelations among monoamine metabolite concentrations in human lumbar CSF are not due to a shared acid transport system

Intercorrelations among homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-hydroxy-phenylglycol (MHPG) concentrations in lumbar cerebrospinal fluid (CSF) were examined before and after blockade of the acid transport system by probenecid in 59 psychiatric inpatients. The three compounds remained intercorrelated despite acid transport blockade, suggesting that the common transport system does not account for their covariance. Other possibilities to explain the interrelationship among these compounds are discussed.

[The effect of the cerebrospinal fluid from patients with manic and depressive syndromes on the social hierarchical relationships in a group of rats]

Taking into account socio-oriented symptoms of affective disorders, a method of zoosocial hierarchy of rats was used for biological testing of the cerebrospinal fluid of patients with manic and depressive syndromes. Cerebrospinal fluid and its fractions were administered before and after treatment by trypsin into suboccipital cistern of "dominants" and "subordinates" of the community. A change of behaviour was observed, the character of which depended on the phase of donor's psychosis. Low-molecular fraction of the cerebrospinal fluid possessed specific activity, which disappeared after the treatment by trypsin, what allowed to suggest oligopeptide nature of the active factors.