A unifying hypothesis of schizophrenia: abnormal immune system development may help explain roles of prenatal hazards, post-pubertal onset, stress, genes, climate, infections, and brain dysfunction

Pro-inflammatory cytokine levels are raised in female schizophrenia patients treated with clozapine

BACKGROUND

We have previously shown that the neurotrophic factor, S100B, is raised in serum samples of female patients with schizophrenia, but not male patients, compared to controls, and this may be associated with raised BMI. Here we analysed the levels of additional proinflammatory cytokines in patients with schizophrenia to further investigate these gender differences.

METHODS

The levels of six cytokines (IL1β, IL6, IL8, IL17, IL23, TNFα) were measured in serum samples obtained from patients with schizophrenia, treated with clozapine (n=91) and compared with healthy controls (n=50). Individual cytokine levels were measured using dot-immunoblotting methods and a 'cytokine signature' was also generated by summing all 6 cytokines. Treatment time, patient age, gender, illness severity and metabolic parameters were also measured.

RESULTS

The levels of proinflammatory cytokines and BMI were significantly raised in female, but not male, patients treated with clozapine compared to healthy controls. Compared to individual cytokines, the 'cytokine signature' analysis showed less scatter of data although this 'cytokine signature' method did not improve separation of individual patients and controls.

CONCLUSIONS

This study supports previous findings that raised BMI, which is likely associated with increased number of adipocytes, may contribute to increased cytokine serum concentrations in females.

Inflammatory cytokine network in schizophrenia

OBJECTIVES

The purpose of this review is to analyse, sum up and discuss the available literature on the role of inflammation and inflammatory cytokines in the pathogenesis of schizophrenia.

METHODS

An electronic literature search of peer-reviewed English language articles using Pubmed was undertaken. These articles together with those published by us provided the background for the present review.

RESULTS

An overview of the available literature on this issue clearly demonstrated the alterations in mRNA and protein expression levels of several proinflammatory and chemotactic cytokines in patients with schizophrenia. Importantly, some of these changes are genetically determined. It was noteworthy that, depending on the study population, some variations of the data obtained are detected.

CONCLUSIONS

Altered inflammatory cytokine production, both genetically and environmentally determined, is implicated in schizophrenia and contributes to disease-associated low-grade systemic inflammation. Proinflammatory and chemotactic cytokines and their receptors may represent additional therapeutic targets for treatment of schizophrenia.

Is elevated norepinephrine an etiological factor in some cases of schizophrenia?

A number of hypotheses have been put forth regarding the etiology of schizophrenia, including the dopamine hypothesis, NMDA receptor hypofunction hypothesis, and others. A lesser known theory is that elevated noradrenergic signaling plays a causative role in the disease. This paper briefly re-examines the merits of this hypothesis, including as it relates to some recently published studies. Several lines of evidence are investigated, including: endogenous level studies of norepinephrine (NE); modulation of the disease by noradrenergic drugs; association of the disease with bipolar disorder and hypertension, since these latter two conditions may involve elevated NE transmission; and effects of psychological stress on the disease, since stress can produce elevated release of NE. For many of these lines of evidence, their relationship with prepulse inhibition of startle is examined. A number of these studies support the hypothesis, and several suggest that elevated NE signaling plays a particularly prominent role in the paranoid subtype of schizophrenia. If the hypothesis is correct for some persons, conventional pharmaceutical treatment options, such as use of atypical antipsychotics (which may themselves modulate noradrenergic signaling), may be improved if selective NE transmission modulating agents are added to or even substituted for these conventional drugs.

Anti-brain autoantibodies in the serum of schizophrenic patients: a case-control study

Schizophrenia is considered a neurodevelopmental disorder with a multifactorial pathogenesis where autoimmune factors may play a significant role. The aim of this study was to verify the presence of anti-brain autoantibodies in the serum of schizophrenic patients compared to healthy controls. Autoantibodies against brain were detected by the immunofluorescence method, utilizing sections of rat hippocampus and hypothalamus and of monkey cerebellum. Three different fluorescence patterns were observed, staining the nucleus-cytoplasm of neurons, the neuroendothelial of blood vessel and the neurofilaments. Search for other organ-specific and non organ-specific autoantibodies was performed in all sera by indirect immunofluorescence method, enzyme linked immunosorbent assay and chemiluminescence immunoassay. Results showed a significant association between schizophrenia and anti-brain autoantibodies against the neuroendothelium of blood vessel in hypothalamus, hippocampus and cerebellum; a significant nuclear and cytoplasmic staining of neurons was assessed only for the hippocampus. No other significant association was found, except between schizophrenia and anti-nuclear autoantibodies on HEp-2 cells. In conclusion, these results support the hypothesis of a significant association between schizophrenia and circulating anti-brain autoantibodies, suggesting a diffuse reactivity against the neuroendothelium of blood vessel and highlighting a nuclear and cytoplasmic staining of the neurons of hippocampus.

Will brain cells derived from induced pluripotent stem cells or directly converted from somatic cells (iNs) be useful for schizophrenia research?

The reprogramming of nonneuronal somatic cells to induced pluripotent stem cells and their derivation to functional brain cells as well as the related methods for direct conversion of somatic cells to neurons have opened up the possibility of conducting research on cellular disease models from living schizophrenia patients. We review the published literature on schizophrenia that has used this rapidly developing technology, highlighting the need for specific aims and reproducibility. The key issues for consideration for future schizophrenia research in this field are discussed and potential investigations using this technology are put forward for critical assessment by the reader.

Autoantibodies and the immune hypothesis in psychotic brain diseases: challenges and perspectives

The pathophysiology of psychosis is poorly understood, with both the cognitive and cellular changes of the disease process remaining mysterious. There is a growing body of evidence that points to dysfunction of the immune system in a subgroup of patients with psychosis. Recently, autoantibodies directed against neuronal cell surface targets have been identified in a range of syndromes that feature psychosis. Of interest is the detection of autoantibodies in patients whose presentations are purely psychiatric, such as those suffering from schizophrenia. Autoantibodies have been identified in a minority of patients, suggesting that antibody-associated mechanisms of psychiatric disease likely only account for a subgroup of cases. Recent work has been based on the application of cell-based assays-a paradigm whose strength lies in the expression of putative antigens in their natural conformation on the surface of live cells. The responsiveness of some of these newly described clinical syndromes to immune therapy supports the hypothesis that antibody-associated mechanisms play a role in the pathogenesis of psychotic disease. However, further investigation is required to establish the scope and significance of antibody pathology in psychosis. The identification of a subgroup of patients with antibody-mediated disease would promise more effective approaches to the treatment of these high-morbidity conditions.

Evaluation of polymorphism, hypermethylation and expression pattern of CTLA4 gene in a sample of Iranian patients with schizophrenia

The cytotoxic T lymphocyte-associated antigen 4 gene (CTLA4) has a crucial role in regulation of T cell proliferation and mediates T cell apoptosis by encoding the T cell receptor. Schizophrenia (SCZ) patients often have abnormalities in terms of the function and development of the immune system. The aim of the present study was to investigate promoter variation and expression profile of the CTLA4 gene in patients with SCZ. We isolated genomic DNA from peripheral blood of 94 individuals with SCZ and 99 healthy control subjects. Genotypic analysis of CTLA4 (-318) was done by Tetra-ARMS-PCR. Methylation-specific polymerase chain reaction (MS-PCR) was used to estimate promoter hypermethylation of the CTLA4 gene. In addition, we investigated CTLA4 mRNA levels in 34 blood samples from cases and healthy controls using real-time reverse transcription PCR. The CT genotype of CTLA4 has a significantly protective effect on the risk to SCZ (OR=0.44; 95% CI 0.18-1.06, P=0.007) in comparison with the wild CC genotype. Promoter methylation of the CTLA4 gene increased the risk of disease statistically (OR=3.82, 95% CI 1.34-10.9, P=0.015) in cases when compared to healthy controls in blood samples. The mRNA expression level results showed statistically significant differences (P<0.0001) between cases (n=17) and healthy controls (n=17). To the best of our knowledge, this is the first evidence showing that promoter methylation of the CTLA4 gene along with transition of C to T was linked to a significantly higher expression of CTLA4 mRNA levels in patients with SCZ.

Gene expression analysis reveals schizophrenia-associated dysregulation of immune pathways in peripheral blood mononuclear cells

Peripheral blood mononuclear cells (PBMCs) represent an accessible tissue source for gene expression profiling in schizophrenia that could provide insight into the molecular basis of the disorder. This study used the Illumina HT_12 microarray platform and quantitative real time PCR (QPCR) to perform mRNA expression profiling on 114 patients with schizophrenia or schizoaffective disorder and 80 non-psychiatric controls from the Australian Schizophrenia Research Bank (ASRB). Differential expression analysis revealed altered expression of 164 genes (59 up-regulated and 105 down-regulated) in the PBMCs from patients with schizophrenia compared to controls. Bioinformatic analysis indicated significant enrichment of differentially expressed genes known to be involved or associated with immune function and regulating the immune response. The differential expression of 6 genes, EIF2C2 (Ago 2), MEF2D, EVL, PI3, S100A12 and DEFA4 was confirmed by QPCR. Genome-wide expression analysis of PBMCs from individuals with schizophrenia was characterized by the alteration of genes with immune system function, supporting the hypothesis that the disorder has a significant immunological component in its etiology.

Label-free quantitative proteomic analysis reveals dysfunction of complement pathway in peripheral blood of schizophrenia patients: evidence for the immune hypothesis of schizophrenia

Schizophrenia is a complex mental disease caused by a combination of serial alterations in genetic and environmental factors. Although the brain is usually considered as the most relevant organ in schizophrenia, accumulated evidence suggests that peripheral tissues also contribute to this disease. In particular, abnormalities of the immune system have been identified in the peripheral blood of schizophrenia patients. To screen the serum proteomic signature of schizophrenia patients, we conducted shotgun proteomic analysis on serum samples of schizophrenia patients and healthy controls. High-abundance proteins were eliminated by immunoaffinity before LC-MS/MS analysis. The multivariate statistical test partial least squares-discriminant analysis (PLS-DA) was applied to build models for screening out variable importance in the projection (VIP) and 27 proteins were identified as being responsible for discriminating between the proteomic profiles of schizophrenia patients and healthy controls. Pathway analysis based on these 27 proteins revealed that complement and coagulation cascades was the most significant pathway. ELISA-based activity analyses indicated that the alternative complement pathway was suppressed in schizophrenia patients. Ingenuity pathways analysis was used to conduct the interaction network of 27 proteins. The network exhibited common features such as, nervous system development and function, humoral immune response and inflammatory response, and highlighted some proteins with important roles in the immune system, such as hub nodes. Our findings indicate dysregulation of the alternative complement pathway in schizophrenia patients. The protein interaction network enhances the interpretation of proteomic data and provides evidence that the immune system may contribute to schizophrenia.

Altered immune function in unaffected first-degree biological relatives of schizophrenia patients

Inflammatory and immune processes have been implicated in the etiopathology of schizophrenia. We demonstrate the existence of immune function alteration, assessed by serum cytokine's levels, not only in schizophrenia patients but also in their unaffected first-degree relatives. This finding may provide a new data for considering cytokines as schizophrenic disease biomarkers.

Explorando o componente inflamatório da esquizofrenia

A esquizofrenia é uma doença heterogênea caracterizada por um conjunto de manifestações clínicas. Um grande número de estudos ao longo dos últimos 20 anos apontou para anormalidades no sistema imune em pacientes que sofrem dessa condição. Em adição, tem sido mostrado que a psicose e a disfunção cognitiva associadas com a esquizofrenia estão ligadas a doenças autoimunes. Aqui, revisamos a evidência que sugere que um status pró-inflamatório do sistema imune induz sintomas psicopatológicos e pode estar envolvido na fisiopatologia dessa principal doença mental. Também propomos que futuros estudos pré-clínicos e clínicos deveriam levar em conta tais causas predefinidas e o status do componente inflamatório. Estratificação de pacientes e estratégias de medicina personalizadas baseadas no direcionamento ao componente inflamatório da doença poderiam ajudar na redução de sintomas e da progressão da doença. Por fim, isso poderia levar a novos conceitos na identificação de alvos moleculares em esquizofrenia e estratégias de descoberta de drogas.

Elevated levels of circulating IL-18BP and perturbed regulation of IL-18 in schizophrenia

Background

The pleiotropic pro-inflammatory cytokine Interleukin (IL)-18 has been proposed to play a role in schizophrenia, since elevated circulating levels of its protein and altered frequencies of genetic variants in its molecular system are reported in schizophrenic patients.

Methods

We analyzed 77 patients with schizophrenia diagnosis (SCZ) and 77 healthy control subjects (HC) for serum concentration of both IL-18 and its natural inhibitor, the IL-18 binding protein (IL-18BP).

Results

We confirmed that serum levels of total IL-18 are significantly increased in SCZ, as compared to HC. However, due to a highly significant increase in levels of circulating IL-18BP in SCZ, as compared to HC, the levels of free, bioactive IL-18 are not significantly different between the two groups. In addition, the relationships between the levels of IL-18 and its inhibitor, as well as between the two molecules and age appear dissimilar for SCZ and HC. In particular, the elevated levels of IL-18BP, likely a consequence of the body’s attempt to counteract the early prominent inflammation which characterizes schizophrenia, are maintained in earlier and later stages of the disease. However, the IL-18BP elevation appears ineffective to balance the IL-18 system in younger SCZ patients, while in older patients the levels of circulating bioactive IL-18 are comparable to those of HC, if not lower.

Conclusions

In conclusion, these findings indicate that the IL-18 system is perturbed in schizophrenia, supporting the idea that this pro-inflammatory cytokine might be part of a pathway of genetic and environmental components for vulnerability to the disease.

Prenatal and perinatal risk factors of schizophrenia

Schizophrenia could be considered the most severe of all psychiatric disorders. It shows a heterogeneous clinical picture and presents an etiopathogenesis that is not cleared sufficiently. Even if the etiopathogenesis remains a puzzle, there is a scientific consensus that it is an expression of interaction between genotype and environmental factors. In the present article, following a study of literature and the accumulated evidence, the role of prenatal and perinatal factors in the development of schizophrenia will be revised and synthesized. We think that better knowledge of the risk factors could be helpful not only for better comprehension of the pathogenesis but especially to optimize interventions for prevention of the disorder.

An association between high birth weight and schizophrenia in a Finnish schizophrenia family study sample

Longitudinal cohort studies have implicated an association between both low and high birth weight and schizophrenia. It has been suggested that schizophrenia associated genes could augment an individual's susceptibility to adverse prenatal and perinatal environmental events. We investigated the association between birth weight and schizophrenia in a large Finnish schizophrenia family study sample. We utilized the birth weight data of 1051 offspring from 315 Finnish families with at least one offspring with a diagnosis of schizophrenia. We used a multivariate COX frailty model to analyze the effect of birth weight on the risk of developing schizophrenia within the families. Using information from the Medication Reimbursement Register and patient interviews, we further investigated the association of maternal type 2 diabetes and schizophrenia risk among offspring. High birth weight (>4000g) was associated with a 1.68-fold increase in schizophrenia susceptibility. Maternal diabetes at the time of data collection, a proxy for gestational diabetes, was associated with a 1.66-fold increase in the risk of developing schizophrenia among offspring. Our results corroborate recent findings showing an association between high birth weight and schizophrenia. Our results also point to a potential birth-weight independent association between maternal type 2 diabetes and schizophrenia among offspring.

Winter birth excess in schizophrenia and in non-schizophrenic psychosis: sex and birth-cohort differences

OBJECTIVE

Despite the fact that association between winter birth excess and schizophrenia in the northern Hemisphere is well established, possible sex or birth-cohort differences in this winter birth excess remain unclear. We aimed to evaluate sex and birth-cohort differences in the seasonal birth distribution of patients with schizophrenia or non-schizophrenic psychosis.

METHOD

The sample included 321 ICD-10 schizophrenia and 294 non-schizophrenic psychosis patients consecutively admitted into a psychiatric hospitalization unit in Granada, southern Spain, during a nine-year period (1998-2006). The distribution of births among the general population born over the same period as the patients was calculated.

RESULTS

Among schizophrenia males (n=258), it was possible to demonstrate that the observed proportion of winter birth (December, January or February) was significantly higher than expected. Among schizophrenia females (n=63), although proportions were as in males and the effect size of the difference between observed and expected winter births was not lower than for men, only a statistical trend could be demonstrated. Among patients with non-schizophrenic psychosis, the observed proportion of winter birth was significantly higher than expected in women, but not in men. The sex-adjusted proportion of winter birth among schizophrenia patients born in the 1940's (a time period characterized by poor economy and widespread food restrictions because of the Spanish post-civil-war period) was significantly higher than among those born later; a difference that does not occur among patients with a non-schizophrenic psychosis.

CONCLUSIONS

Among schizophrenia patients born in winter there appear to be slight sex-differences and strong birth-cohort differences, possibly due to epidemiological factors such as poverty or maternal nutritional deprivation. Epidemiological findings related to winter birth excess among patients with schizophrenia must be identified in longitudinal studies.

Highway to health; or How prenatal factors determine disease risks in the later life of the offspring

Fetal development is largely dependent on the mother. However, pregnancy maintenance and consequently fetal development are highly vulnerable and sensitive to disruption, triggered by, for example, prenatal stress challenge. Such prenatal stress challenge modulates the maternal endocrine and immune responses during pregnancy e.g. by decreasing levels of progesterone. Prenatal stress also has negative repercussions for the child's health later in life. It has been reported that prenatal stress increases the risk of the child to develop chronic immune diseases such as allergies and asthma. We therefore propose that prenatal stress challenge - associated with a decrease in maternal progesterone - impairs fetal immune development (immune ontogeny). Such impaired immune ontogeny carries over into postnatal life, rendering the child more prone to developing chronic immune diseases. This purported association urgently requires a fresh evaluation in order to identify biomarkers and cascades of events. In the present review, we outline candidate biomarkers involved in fetal immune ontogeny, which may be targets of prenatal stress challenge and subsequently determine offspring disease risk. Identification of these stress-sensitive biomarkers may allow detection of pregnant women at risk to deliver chronic immune disease-prone offspring. The creation of therapeutic interventions designed to prevent negative consequences of prenatal stress would then be within reach.

An Evolutionary Hypothesis of Suicide: Why it Could be Biologically Adaptive and is so Prevalent in Certain Occupations

From an evolutionary perspective, suicide is a puzzle, because it has serious adverse effects, yet is remarkably common and heritable. An hypothesis is proposed to explain this puzzle, by explaining how suicide could be adaptive through reducing risk that individuals will transmit infections to kin. Empirical evidence supports four predictions from the hypothesis. There are well-established mechanisms by which infections and immune factors increase risk for mental disorders that contribute to suicide. Suicide is more prevalent in occupations with greater exposure to infection and immune-compromising factors and at higher latitudes, where key environmental factors increase vulnerability to infection. In several other highly social species, suicide-like behaviors have evolved to reduce transmission of infections. If the hypothesis is correct, detection and treatment of underlying infections and immune dysfunction should help predict and prevent suicidal behavior, while also combating spread of infectious diseases.

Effects of exogenous agents on brain development: stress, abuse and therapeutic compounds

The range of exogenous agents likely to affect, generally detrimentally, the normal development of the brain and central nervous system defies estimation although the amount of accumulated evidence is enormous. The present review is limited to certain types of chemotherapeutic and "use-and-abuse" compounds and environmental agents, exemplified by anesthetic, antiepileptic, sleep-inducing and anxiolytic compounds, nicotine and alcohol, and stress as well as agents of infection; each of these agents have been investigated quite extensively and have been shown to contribute to the etiopathogenesis of serious neuropsychiatric disorders. To greater or lesser extent, all of the exogenous agents discussed in the present treatise have been investigated for their influence upon neurodevelopmental processes during the period of the brain growth spurt and during other phases uptill adulthood, thereby maintaining the notion of critical phases for the outcome of treatment whether prenatal, postnatal, or adolescent. Several of these agents have contributed to the developmental disruptions underlying structural and functional brain abnormalities that are observed in the symptom and biomarker profiles of the schizophrenia spectrum disorders and the fetal alcohol spectrum disorders. In each case, the effects of the exogenous agents upon the status of the affected brain, within defined parameters and conditions, is generally permanent and irreversible.

The effects of early adversity on the adult and developing brain

PURPOSE OF REVIEW

Recent advances in neuroimaging methods have provided new ways of unravelling the complex interplay between genetic and environmental factors that influence functional brain development in the critical first years of life. This has allowed new insights into the effects that early adverse experience can exert on the brain later in life. We review recent progress in the characterization of those effects and underlying mechanisms through which adverse environment influences the neurocognitive development.

RECENT FINDINGS

Socioeconomic background may have a profound effect on structural and functional brain development, especially in the domains of language and prefrontal executive control. These effects are mediated by several factors: diet, quality of parental care, impoverished environment, prenatal exposure to toxic substances and so on. Other circumstances such as perinatal brain injury, early sensory deprivation or limb malformation may result in atypical functional organization of the brain and lasting cognitive impairment of certain functions. Early experience of maltreatment or institutionalized care may alter the development of the social brain, contributing to negative mental health outcomes, which may be partially reversed through early intervention programmes.

SUMMARY

Subsequent models of psychiatric disorder should take into account early risk factors and embrace developmental models at multiple levels of biological organization. There is a continuing need for the study of optimal environmental input during sensitive periods in brain development.