The challenge of psychiatric nosology and diagnosis

Molecular Mechanism Biomarkers Predict Diagnosis in Schizophrenia and Schizoaffective Psychosis, with Implications for Treatment

Diagnostic uncertainty and relapse rates in schizophrenia and schizoaffective disorder are relatively high, indicating the potential involvement of other pathological mechanisms that could serve as diagnostic indicators to be targeted for adjunctive treatment. This study aimed to seek objective evidence of methylenetetrahydrofolate reductase MTHFR C677T genotype-related bio markers in blood and urine. Vitamin and mineral cofactors related to methylation and indolamine-catecholamine metabolism were investigated. Biomarker status for 67 symptomatically well-defined cases and 67 asymptomatic control participants was determined using receiver operating characteristics, Spearman's correlation, and logistic regression. The 5.2%-prevalent MTHFR 677 TT genotype demonstrated a 100% sensitive and specific case-predictive biomarkers of increased riboflavin (vitamin B2) excretion. This was accompanied by low plasma zinc and indicators of a shift from low methylation to high methylation state. The 48.5% prevalent MTHFR 677 CC genotype model demonstrated a low-methylation phenotype with 93% sensitivity and 92% specificity and a negative predictive value of 100%. This model related to lower vitamin cofactors, high histamine, and HPLC urine indicators of lower vitamin B2 and restricted indole-catecholamine metabolism. The 46.3%-prevalent CT genotype achieved high predictive strength for a mixed methylation phenotype. Determination of MTHFR C677T genotype dependent functional biomarker phenotypes can advance diagnostic certainty and inform therapeutic intervention.

Chronic fatigue and fibromyalgia symptoms are key components of deficit schizophrenia and are strongly associated with activated immune-inflammatory pathways

There is now evidence that schizophrenia and especially deficit schizophrenia (DefSCZ) (a phenotype characterized by negative symptoms) is accompanied by activated immune-inflammatory pathways. A subset of patients with schizophrenia and DefSCZ experience physiosomatic symptoms reminiscent of chronic fatigue and fibromyalgia. However, there are no data whether, in DefSCZ, physiosomatic symptoms are associated with increased levels of cytokines/chemokines. This study examined the associations between physiosomatic symptoms, as assessed with the FibroFatigue (FF) scale, and symptoms of DefSCZ as well as interleukin IL-1β, IL-1 receptor antagonist (sIL-1RA), tumor necrosis factor (TNF)-α and CCL11 (eotaxin) in 120 DefSCZ patients (as defined by the Schedule for Deficit Schizophrenia) and 54 healthy controls. In DefSCZ, there were robust associations between FF and negative symptoms, psychosis, hostility, excitation, mannerism, psychomotor retardation and formal thought disorders. A latent vector extracted from those DefSCZ symptom domains also loaded highly on the total FF score and showed adequate convergent validity, internal consistency reliability and predictive relevance. The FF score was significantly associated with impairments in semantic and episodic memory and executive functions. Soft Independent Modelling of Class Analogy showed that the FF items discriminated DefSCZ from controls with an 100% accuracy. Interleukin IL-1β, IL-1RA, TNF-α and CCL11 explained 59.4% of the variance in the LV extracted from the FF and DefSCZ symptoms. In conclusion, these data show that physiosomatic symptoms are a core component of DefSCZ phenomenology and are strongly associated with activated immune pathways, which have neurotoxic effects.

The Neuroimmune and Neurotoxic Fingerprint of Major Neurocognitive Psychosis or Deficit Schizophrenia: a Supervised Machine Learning Study

No studies have examined the immune fingerprint of major neurocognitive psychosis (MNP) or deficit schizophrenia using M1 macrophage cytokines in combination with chemokines such as CCL2 and CCL11. The present study delineated the neuroimmune fingerprint of MNP by analyzing plasma levels of IL-1β, sIL-1RA, TNFα, sTNFR1, sTNFR2, CCL2, and CCL11 in 120 MNP versus 54 healthy controls in association with neurocognitive scores (as assessed with the Brief Assessment of Cognition in Schizophrenia) and PHEMN (psychotic, hostility, excitation, mannerism and negative) symptoms. MNP was best predicted by a combination of CCL11, TNFα, IL-1β, and sIL-1RA which yielded a bootstrapped (n = 2000) area under the receiver operating curve of 0.985. Composite scores reflecting M1 macrophage activity and neurotoxic potential including effects of CCL11 and CCL2 were significantly increased in MNP. A large part of the variance in PHEM (38.4-52.6%) and negative (65.8-74.4%) symptoms were explained by combinations of immune markers whereby CCL11 was the most important. The same markers explained a large part of the variance in the Mini-Mental State examination, list learning, digit sequencing task, category instances, controlled word association, symbol coding, and Tower of London. Partial least squares analysis showed that 72.7% of the variance in overall severity of schizophrenia was explained by the regression on IL-1β, sIL-1RA, CCL11, TNFα, and education. It is concluded that the combination of the abovementioned markers defines MNP as a distinct neuroimmune disorder and that increased immune neurotoxicity determines memory and executive impairments and PHEMN symptoms as well.

Beyond the Categorical Distinction Between Borderline Personality Disorder and Bipolar II Disorder Through the Identification of Personality Traits Profiles

BACKGROUND

The relationship between borderline personality disorder (BPD) and type-II bipolar disorder (BDII) is not clearly understood. Nevertheless, in clinical practice and research, most efforts focus on establishing a categorical distinction between the two. We propose using personality traits as a more informative strategy to describe them.

METHODS

Five-Factor Model personality traits were measured in 73 individuals with either BPD or BDII. Latent class cluster analysis was applied to the sample.

RESULTS

A three-cluster model resulted the best fit to the data, where all clusters had high neuroticism and low extraversion scores but differed widely on the other traits. The clusters' boundaries did not match the categorical diagnosis.

CONCLUSIONS

Our sample showed significant heterogeneity on personality traits, which can have a relevant effect on the outcome of each disorder and that was not captured by the categorical diagnosis. Thus, we advocate for a multivariate approach as a better way to understand the relationship between BPD and BDII.

The Reification of Diagnosis in Psychiatry

Invited commentary on: The neuro-immune and neurotoxic fingerprint of major neuro-cognitive psychosis or deficit schizophrenia: a supervised machine learning study, by Maes et Al.

The Role of Aberrations in the Immune-Inflammatory Response System (IRS) and the Compensatory Immune-Regulatory Reflex System (CIRS) in Different Phenotypes of Schizophrenia: the IRS-CIRS Theory of Schizophrenia

Several lines of evidence indicate that aberrations in immune-inflammatory pathways may contribute to the pathophysiology of schizophrenia spectrum disorders. Here, we propose a novel theoretical framework that was previously developed for major depression and bipolar disorder, namely, the compensatory immune-regulatory reflex system (CIRS), as applied to the neuro-immune pathophysiology of schizophrenia and its phenotypes, including first-episode psychosis (FEP), acute relapses, chronic and treatment-resistant schizophrenia (TRS), comorbid depression, and deficit schizophrenia. These schizophrenia phenotypes and manifestations are accompanied by increased production of positive acute-phase proteins, including haptoglobin and α2-macroglobulin, complement factors, and macrophagic M1 (IL-1β, IL-6, and TNF-α), T helper (Th)-1 (interferon-γ and IL-2R), Th-2 (IL-4, IL-5), Th-17 (IL-17), and T regulatory (Treg; IL-10 and transforming growth factor (TGF)-β1) cytokines, cytokine-induced activation of the tryptophan catabolite (TRYCAT) pathway, and chemokines, including CCL-11 (eotaxin), CCL-2, CCL-3, and CXCL-8. While the immune profiles in the different schizophrenia phenotypes indicate the activation of the immune-inflammatory response system (IRS), there are simultaneous signs of CIRS activation, including increased levels of the IL-1 receptor antagonist (sIL-1RA), sIL-2R and tumor necrosis factor-α receptors, Th-2 and Treg phenotypes with increased IL-4 and IL-10 production, and increased levels of TRYCATs and haptoglobin, α2-macroglobulin, and other acute-phase reactants, which have immune-regulatory and anti-inflammatory effects. Signs of activated IRS and CIRS pathways are also detected in TRS, chronic, and deficit schizophrenia, indicating that these conditions are accompanied by a new homeostatic setpoint between upregulated IRS and CIRS components. In FEP, increased baseline CIRS activity is a protective factor that may predict favorable clinical outcomes. Moreover, impairments in the CIRS are associated with deficit schizophrenia and greater impairments in semantic and episodic memory. It is concluded that CIRS plays a key role in the pathophysiology of schizophrenia by negatively regulating the primary IRS and contributing to recovery from the acute phase of illness. Therefore, components of the CIRS may offer promising therapeutic targets for schizophrenia.

Development of a Novel Staging Model for Affective Disorders Using Partial Least Squares Bootstrapping: Effects of Lipid-Associated Antioxidant Defenses and Neuro-Oxidative Stress

Although, staging models gained momentum to stage define affective disorders, no attempts were made to construct mathematical staging models using clinical and biomarker data in patients with major depression and bipolar disorder. The aims of this study were to use clinical and biomarker data to construct statistically derived staging models, which are associated with early lifetime traumata (ELTs), affective phenomenology, and biomarkers. In the current study, 172 subjects participated, 105 with affective disorders (both bipolar and unipolar) and 67 controls. Staging scores were computed by extracting latent vectors (LVs) from clinical data including ELTs, recurring flare ups and suicidal behaviors, outcome data such as disabilities and health-related quality of life (HR-QoL), and paraoxonase (PON)1 actvities and nitro-oxidative stress biomarkers. Recurrence of episodes and suicidal behaviors could reliably be combined into a LV with adequate composite reliability (the "recurrence LV"), which was associated with female sex, the combined effects of multiple ELTs, disabilities, HR-QoL, and impairments in cognitive tests. All those factors could be combined into a reliable "ELT-staging LV" which was significantly associated with nitro-oxidative stress biomarkers. A reliable LV could be extracted from serum PON1 activities, recurrent flare ups, disabilities, and HR-QoL. Our ELT-staging index scores the severity of a relevant affective dimension, shared by both major depression and bipolar disorder, namely the trajectory from ELTs, a relapsing course, and suicidal behaviors to progressive disabilities. Patients were classified into three stages, namely an early stage, a relapse-regression stage, and a suicidal-regression stage. Lowered lipid-associated antioxidant defenses may be a drug target to prevent the transition from the early to the later regression stages.

Cross-Validation of Paranoid-Depressive Scale and Functional MRI: New Paradigm for Neuroscience Informed Clinical Psychopathology

There is reported a study performed with a novel paradigm aiming at investigation of the translational validity of von Zerssen's paranoid-depression scale and its fMRI correlates in terms of focus on exploration of the results on the contrast between the Paranoid Specific (DP) blocks and the Depression Specific (DS) blocks. Patients with schizophrenia demonstrated significant activations in a number of regions (right angular gyrus, left posterior cingulate and precuneus, right transverse temporal gyrus) during responses to paranoia versus depression items which differ topologically from those found in patients with major depression (left middle cingulate and right superior temporal gyrus). The direct comparison between the groups, however, did not yield any residual activations after correction.

Indeterminacy of definitions and criteria in mental health: case study of emotional disorders

RATIONALE, AIMS AND OBJECTIVES

The concept of emotions has gone through radical transformations during the last couple of centuries. Despite these severe re-specifications of its content, the concept of emotions (and especially some such as depression or anxiety) has acquired a central role in contemporary clinical Psychology and Psychiatry. This creates an apparent paradox, utilizing more and more concepts for which no clear conceptual understanding has been obtained. This paradox creates a challenge for researchers as well as clinicians, as on a daily basis, millions of people are currently ascribed with 'having' or 'being in' emotional states, which also entails certain interventions to be applied, without much clear insight into what exactly those states might really constitute.

METHOD

Conceptual research in aetiological and historical transformation of theoretical accounts of emotions as well as an overview of relevant empirical research on fundamental emotions. Examining of critical respective questions such as: whether there are any universal 'typical' emotional reactions to be found in each and every known culture, indicating their intrinsic existence as being a part of the human condition; whether there are 'basic' and 'secondary' emotions; whether emotions are merely bodily events, patterns of behavioural reactions to given types of stimuli or whether they rely inevitably on their cognitive content; whether emotions are necessarily intentional (in Brentano's sense) viz. are inevitably about a real or an imaginary object or whether there can be objectless emotional states; whether emotions are in a significant sense rational or fundamentally irrational responses and so forth. Moreover, more recent experimental data advocating for one or the other response to the aforementioned fundamental questions are scrutinized.

RESULTS

In both conceptual research (including the works of thinkers such as the highly influential contributions of Darwin, James, Cannon, Freud, Ryle and Sartre or contemporary attempts such as the ones of theorists like Solomon, Nash, Rey, Pugmire and Lyons) as well as in comprehensive theoretical schemes combining experimental data (such as the ones provided by the works of Schachter and Singer, Ekman and Friesen, Panksepp, Damasio and Griffiths), there seems to be a radical indeterminacy of conceptual content and fundamental features of emotions in general, as well as of particular emotional states. Furthermore, there is an apparent conceptual incapability to include each and every feature of emotional states within a single comprehensive definition without making reference to contingent particularities of their biological instantiation.

CONCLUSIONS

At least in the crucial concept of emotional states, when examined carefully, it seems that (1) there are substantial barriers to the ambitious quest for a scientific grounding of taxonomies and definitions of phenomena like emotions, due to the inability to provide an independent verification of scientific propositions; (2) all major approaches in Psychology and Psychiatry seem to have serious shortcomings in defining emotions; (3) such shortcomings have to do with fundamental issues such as the nature of mental states; (4) most ordinary concepts of emotions utilized by clinicians and researchers tend to be circular and question begging when scrutinized theoretically; and (5) historically dominant beliefs, values and cultural systems tend to influence heavily both the acceptability of such representations of emotions as well as their very nature.

Epistemological and methodological significance of quantitative studies of psychomotor activity for the explanation of clinical depression

RATIONALE, AIMS AND OBJECTIVES

Psychomotor disturbances have been regarded as cardinal symptoms of depression for centuries and their objective assessment may have predictive value with respect to the severity of clinical depression, treatment outcome and prognosis of the affective disorder.

METHODS

Montgomery-Åsberg Depression Rating Scale (MADRS) and Hamilton Rating Scale for Anxiety (HAM-A). Psychomotor indicators of activity and reactivity were objectively recorded and measured by means of computerized ultrasonographic craniocorpography.

RESULTS

We found a statistically significant correlation between disturbances in psychomotor indicators and MADRS total score (r = 0.4; P < 0.0001). The severity of HAM-A total score had no statistically significant correlation with psychomotor indicators (P > 0.05). We found that different items of MADRS and HAM-A correlated with psychomotor disturbances of different strength and significance. Objectively, measured psychomotor retardation was associated with greater severity of depressive symptoms assessed at the clinical level.

CONCLUSIONS

Integration between different methods is needed in order to improve understanding of the psychopathology and the neurobiology of a disputable diagnosis such as clinical depression.