Psychopharmacology of Williams syndrome: safety, tolerability, and effectiveness

Levodopa-responsive dystonia, parkinsonism, and treatment-resistant schizoaffective disorder in Williams syndrome

BACKGROUND

Williams syndrome (WS; chromosome 7q11.23 deletion) is a rare, multisystemic, neurodevelopmental disorder with variable penetrance and expressivity. Although movement and psychiatric disorders are known to occur in individuals with WS, parkinsonism, dystonia, and treatment-resistant schizoaffective disorder have not been formally described.

METHODS

We present two unrelated cases of adults with molecularly confirmed WS and typical histories of developmental delays, intellectual/learning disabilities, and treatment-responsive anxiety/mood disorder who developed similar noteworthy neuropsychiatric expressions. We reviewed detailed neuropsychiatric histories, laboratory investigations, neuroimaging, and treatment responses and compared data for the two cases.

RESULTS

Both individuals developed treatment-resistant schizoaffective disorder in adulthood requiring multiple trials of antipsychotic treatments. While on clozapine, both patients developed parkinsonism and generalized dystonia with truncal involvement that responded to trials of low-dose levodopa without exacerbating underlying psychotic or affective symptoms.

CONCLUSION

This report illustrates the novel occurrence of levodopa-responsive movement disorders and treatment-resistant schizoaffective disorder in individuals with WS, adding to the expanding neuropsychiatric phenotypes, and highlighting potential shared underlying mechanisms. The observed treatment response suggests that levodopa, in relatively low doses, may be safe and useful in ameliorating presumed antipsychotic-associated parkinsonism and tardive dystonia in WS.

Neuroimaging research in Williams syndrome: Beginning to bridge the gap with clinical care

Williams syndrome (WS) is a genetic disorder affecting multiple organ systems. Cardinal features include cardiovascular disease, distinct facies, and a unique cognitive profile characterized by intellectual disability, hypersociability, and visuospatial weaknesses. Here, we synthesize neuroimaging research in WS with a focus on how the current literature and future work may be leveraged to improve health and quality of life in WS. More than 80 neuroimaging studies in WS have been conducted, the vast majority of which have focused on identifying morphometric brain differences. Aside from decreased volume of the parieto-occipital region and increased cerebellar volume, morphometric findings have been variable across studies. fMRI studies investigating the visuospatial deficit have identified dorsal stream dysfunction and abnormal activation of the hippocampal formation. Minimal work has been done using PET or MRS. Future approaches that conduct neuroimaging in tandem with clinical phenotyping, utilize novel imaging techniques to visualize brain vasculature or provide biochemical and molecular information, and include more homogenous age groups across the lifespan, have significant potential to advance clinical care.

Body mass index variation in adults with Williams syndrome: associations with predicted dietary intake and food behaviors

Background

Dietary intake and body weight are important predictors of long-term health. However, few studies have focused on these topics in adults with genetic syndromes that have associated intellectual disability, such as Williams syndrome (WS).

Objective

In adults with WS, describe predicted dietary intake, food-related problems, and associations between body mass index (BMI) and possible factors contributing to differences in weight status.

Design

In this study of 82 participants (median age of 30 years, range 18-69), we cross sectionally investigated associations between BMI, predicted dietary intakes (Dietary Screener Questionnaire), food-related behaviors (Food-Related Problem Questionnaire), and anxiety (Spence Children's Anxiety Scale). Longitudinal patterns of weight change were further studied in a subset (n = 41).

Results

BMI variation was observed with median BMI of 27.3 kg/m² (range 16.7-55.5 kg/m²). Several components of dietary intake deviated from recommendations in the WS cohort. When compared with WS participants with either normal or overweight BMI, WS participants with obesity had reduced daily intake of fruits and vegetables of 0.15 cup equivalents (P = 0.049), while participants with underweight BMI had reduced daily intake of fruits and vegetables of 0.44 cup equivalents (P = 0.026) and additionally had reduced intake of dietary fiber of 2.12 grams per day (P = 0.019). A one-point increase in the 'preoccupation with food' sub-score was associated with a 0.57 unit increase in BMI (P = 0.16), while a one-point increase in the 'takes and stores food' sub-score was associated with a 0.72 unit increase in BMI. In the longitudinal weight subset, a weight gain group and a weight stable group were identified. The former was associated with increased 'takes and stores food' sub-score but not with dietary intakes.

Conclusion

We observed considerable BMI variability. While few dietary intakes were associated with BMI, increased BMI and weight gain were associated with 'preoccupation with food' and with 'takes and stores food' behavior sub-scores.

Psychotic Symptoms and Malignant Neuroleptic Syndrome in Williams Syndrome: A Case Report

BACKGROUND

Somatic and mental comorbidities are characteristic of individuals with Williams syndrome. The psychiatric profile of these patients mainly comprises affective disorders, while psychotic symptoms are rare.

METHODS

We present a case report of psychosis and malignant neuroleptic syndrome in a patient with Williams syndrome. We also conduct a review of recent works on the topic.

CASE PRESENTATION

A 38-year-old Caucasian male with Williams syndrome presented with somatic delusions, previously experiencing severe anxiety and concerns about a headache. The patient was prescribed olanzapine, which did not, however, have any effect on the delusions. After switching to lurasidone, the patient presented with malignant neuroleptic syndrome (muscle rigidity, tremor, urinary retention, fluctuating level of consciousness). He was hospitalized and the antipsychotic medication was discontinued. After somatic recovery, the patient did not experience severe anxiety and the somatic delusions diminished notably. The patient was discharged from the hospital in a stable physical condition, albeit still with transient worries about his health condition.

CONCLUSIONS

We present a case of the coincidence of Williams syndrome and psychosis. We hypothesize on the possible pathological relationships between the onset of the psychosis and severe anxiety in an individual with Williams syndrome. This case report duly contributes to the limited literature on psychiatric comorbidity in Williams syndrome.

Williams syndrome

Williams syndrome (WS) is a relatively rare microdeletion disorder that occurs in as many as 1:7,500 individuals. WS arises due to the mispairing of low-copy DNA repetitive elements at meiosis. The deletion size is similar across most individuals with WS and leads to the loss of one copy of 25-27 genes on chromosome 7q11.23. The resulting unique disorder affects multiple systems, with cardinal features including but not limited to cardiovascular disease (characteristically stenosis of the great arteries and most notably supravalvar aortic stenosis), a distinctive craniofacial appearance, and a specific cognitive and behavioural profile that includes intellectual disability and hypersociability. Genotype-phenotype evidence is strongest for ELN, the gene encoding elastin, which is responsible for the vascular and connective tissue features of WS, and for the transcription factor genes GTF2I and GTF2IRD1, which are known to affect intellectual ability, social functioning and anxiety. Mounting evidence also ascribes phenotypic consequences to the deletion of BAZ1B, LIMK1, STX1A and MLXIPL, but more work is needed to understand the mechanism by which these deletions contribute to clinical outcomes. The age of diagnosis has fallen in regions of the world where technological advances, such as chromosomal microarray, enable clinicians to make the diagnosis of WS without formally suspecting it, allowing earlier intervention by medical and developmental specialists. Phenotypic variability is considerable for all cardinal features of WS but the specific sources of this variability remain unknown. Further investigation to identify the factors responsible for these differences may lead to mechanism-based rather than symptom-based therapies and should therefore be a high research priority.