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Herrera CG, Tarokh L. A Thalamocortical Perspective on Sleep Spindle Alterations in Neurodevelopmental Disorders. CURRENT SLEEP MEDICINE REPORTS 2024; 10:103-118. [PMID: 38764858 PMCID: PMC11096120 DOI: 10.1007/s40675-024-00284-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 05/21/2024]
Abstract
Purpose of Review Neurodevelopmental disorders are a group of conditions that affect the development and function of the nervous system, typically arising early in life. These disorders can have various genetic, environmental, and/or neural underpinnings, which can impact the thalamocortical system. Sleep spindles, brief bursts of oscillatory activity that occur during NREM sleep, provide a unique in vivo measure of the thalamocortical system. In this manuscript, we review the development of the thalamocortical system and sleep spindles in rodent models and humans. We then utilize this as a foundation to discuss alterations in sleep spindle activity in four of the most pervasive neurodevelopmental disorders-intellectual disability, attention deficit hyperactivity disorder, autism, and schizophrenia. Recent Findings Recent work in humans has shown alterations in sleep spindles across several neurodevelopmental disorders. Simultaneously, rodent models have elucidated the mechanisms which may underlie these deficits in spindle activity. This review merges recent findings from these two separate lines of research to draw conclusions about the pathogenesis of neurodevelopmental disorders. Summary We speculate that deficits in the thalamocortical system associated with neurodevelopmental disorders are exquisitely reflected in sleep spindle activity. We propose that sleep spindles may represent a promising biomarker for drug discovery, risk stratification, and treatment monitoring.
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Affiliation(s)
- Carolina Gutierrez Herrera
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Rosenbühlgasse 25, Bern, Switzerland
- Center for Experimental Neurology, Department of Neurology, Inselspital University Hospital Bern, University of Bern, Rosenbühlgasse 17, Bern, Switzerland
- Department of Biomedical Research (DBMR), Inselspital University Hospital Bern, University of Bern, Murtenstrasse 24 CH-3008 Bern, Bern, Switzerland
| | - Leila Tarokh
- Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Haus A, 3000, Bern, Switzerland
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Haus A, 3000, Bern, Switzerland
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2
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Wang B, Irizar H, Thygesen JH, Zartaloudi E, Austin-Zimmerman I, Bhat A, Harju-Seppänen J, Pain O, Bass N, Gkofa V, Alizadeh BZ, van Amelsvoort T, Arranz MJ, Bender S, Cahn W, Stella Calafato M, Crespo-Facorro B, Di Forti M, Giegling I, de Haan L, Hall J, Hall MH, van Haren N, Iyegbe C, Kahn RS, Kravariti E, Lawrie SM, Lin K, Luykx JJ, Mata I, McDonald C, McIntosh AM, Murray RM, Picchioni M, Powell J, Prata DP, Rujescu D, Rutten BPF, Shaikh M, Simons CJP, Toulopoulou T, Weisbrod M, van Winkel R, Kuchenbaecker K, McQuillin A, Bramon E. Psychosis Endophenotypes: A Gene-Set-Specific Polygenic Risk Score Analysis. Schizophr Bull 2023; 49:1625-1636. [PMID: 37582581 PMCID: PMC10686343 DOI: 10.1093/schbul/sbad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND AND HYPOTHESIS Endophenotypes can help to bridge the gap between psychosis and its genetic predispositions, but their underlying mechanisms remain largely unknown. This study aims to identify biological mechanisms that are relevant to the endophenotypes for psychosis, by partitioning polygenic risk scores into specific gene sets and testing their associations with endophenotypes. STUDY DESIGN We computed polygenic risk scores for schizophrenia and bipolar disorder restricted to brain-related gene sets retrieved from public databases and previous publications. Three hundred and seventy-eight gene-set-specific polygenic risk scores were generated for 4506 participants. Seven endophenotypes were also measured in the sample. Linear mixed-effects models were fitted to test associations between each endophenotype and each gene-set-specific polygenic risk score. STUDY RESULTS After correction for multiple testing, we found that a reduced P300 amplitude was associated with a higher schizophrenia polygenic risk score of the forebrain regionalization gene set (mean difference per SD increase in the polygenic risk score: -1.15 µV; 95% CI: -1.70 to -0.59 µV; P = 6 × 10-5). The schizophrenia polygenic risk score of forebrain regionalization also explained more variance of the P300 amplitude (R2 = 0.032) than other polygenic risk scores, including the genome-wide polygenic risk scores. CONCLUSIONS Our finding on reduced P300 amplitudes suggests that certain genetic variants alter early brain development thereby increasing schizophrenia risk years later. Gene-set-specific polygenic risk scores are a useful tool to elucidate biological mechanisms of psychosis and endophenotypes, offering leads for experimental validation in cellular and animal models.
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Affiliation(s)
- Baihan Wang
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Haritz Irizar
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johan H Thygesen
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
| | - Eirini Zartaloudi
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Isabelle Austin-Zimmerman
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anjali Bhat
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Jasmine Harju-Seppänen
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Oliver Pain
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Nick Bass
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Vasiliki Gkofa
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Behrooz Z Alizadeh
- University of Groningen, University Medical Center Groningen, University Center for Psychiatry, Rob Giel Research Center, Groningen, The Netherlands
- Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Therese van Amelsvoort
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Maria J Arranz
- Fundació Docència i Recerca Mutua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Institut de Recerca Biomédica Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Stephan Bender
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Wiepke Cahn
- Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Altrecht, General Mental Health Care, Utrecht, The Netherlands
| | - Maria Stella Calafato
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Benedicto Crespo-Facorro
- CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Sevilla, Spain
- Department of Psychiatry, University Hospital Virgen del Rocio, School of Medicine, University of Sevilla–IBiS, Sevilla, Spain
| | - Marta Di Forti
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Ina Giegling
- Comprehensive Centers for Clinical Neurosciences and Mental Health (C3NMH), Medical University of Vienna, Austria
| | - Lieuwe de Haan
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Arkin, Institute for Mental Health, Amsterdam, The Netherlands
| | - Jeremy Hall
- Neuroscience and Mental Health Innovation Institute, School of Medicine, Cardiff University, Hadyn Ellis Building, Mandy Road, Cardiff, UK
| | - Mei-Hua Hall
- Psychosis Neurobiology Laboratory, Harvard Medical School, McLean Hospital, Belmont, MA, USA
| | - Neeltje van Haren
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center, Sophia’s Children Hospital, Rotterdam, The Netherlands
| | - Conrad Iyegbe
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - René S Kahn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eugenia Kravariti
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Stephen M Lawrie
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, UK
| | - Kuang Lin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jurjen J Luykx
- Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Translational Neuroscience, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ignacio Mata
- Fundacion Argibide, Pamplona, Spain
- CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Madrid, Spain
| | - Colm McDonald
- The Centre for Neuroimaging & Cognitive Genomics (NICOG) and NCBES Galway Neuroscience Centre, University of Galway, Galway, Ireland
| | - Andrew M McIntosh
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Robin M Murray
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | - Marco Picchioni
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- St Magnus Hospital, Surrey, UK
| | - John Powell
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Diana P Prata
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciencias da Universidade de Lisboa, Portugal
| | - Dan Rujescu
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Division of General Psychiatry, Medical University of Vienna, Austria
| | - Bart P F Rutten
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Madiha Shaikh
- North East London Foundation Trust, London, UK
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Claudia J P Simons
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
- GGzE Institute for Mental Health Care, Eindhoven, The Netherlands
| | - Timothea Toulopoulou
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Interdisciplinary Program in Neuroscience, Aysel Sabuncu Brain Research Center, Bilkent University, Ankara, Türkiye
- National Magnetic Resonance Research Center (UMRAM), Bilkent University, Ankara, Türkiye
- Department of Psychology, Bilkent University, Ankara, Türkiye
- School of Medicine, Department of Psychiatry, National and Kapodistrian University of Athens, Athens, Greece
- Department of Psychiatry and Behavioral Health System, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Matthias Weisbrod
- Department of General Psychiatry, Center of Psychosocial Medicine, University of Heidelberg, Germany
- SRH Klinikum, Karlsbad-Langensteinbach, Germany
| | - Ruud van Winkel
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
- KU Leuven, Department of Neuroscience, Research Group Psychiatry, Leuven, Belgium
| | - Karoline Kuchenbaecker
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
- UCL Genetics Institute, Division of Biosciences, University College London, London, UK
| | - Andrew McQuillin
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
| | - Elvira Bramon
- Department of Mental Health Neuroscience, Division of Psychiatry, University College London, London, UK
- Institute of Cognitive Neuroscience, University College London, London, UK
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Singh NM, Harrod JB, Subramanian S, Robinson M, Chang K, Cetin-Karayumak S, Dalca AV, Eickhoff S, Fox M, Franke L, Golland P, Haehn D, Iglesias JE, O'Donnell LJ, Ou Y, Rathi Y, Siddiqi SH, Sun H, Westover MB, Whitfield-Gabrieli S, Gollub RL. How Machine Learning is Powering Neuroimaging to Improve Brain Health. Neuroinformatics 2022; 20:943-964. [PMID: 35347570 PMCID: PMC9515245 DOI: 10.1007/s12021-022-09572-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 12/31/2022]
Abstract
This report presents an overview of how machine learning is rapidly advancing clinical translational imaging in ways that will aid in the early detection, prediction, and treatment of diseases that threaten brain health. Towards this goal, we aresharing the information presented at a symposium, "Neuroimaging Indicators of Brain Structure and Function - Closing the Gap Between Research and Clinical Application", co-hosted by the McCance Center for Brain Health at Mass General Hospital and the MIT HST Neuroimaging Training Program on February 12, 2021. The symposium focused on the potential for machine learning approaches, applied to increasingly large-scale neuroimaging datasets, to transform healthcare delivery and change the trajectory of brain health by addressing brain care earlier in the lifespan. While not exhaustive, this overview uniquely addresses many of the technical challenges from image formation, to analysis and visualization, to synthesis and incorporation into the clinical workflow. Some of the ethical challenges inherent to this work are also explored, as are some of the regulatory requirements for implementation. We seek to educate, motivate, and inspire graduate students, postdoctoral fellows, and early career investigators to contribute to a future where neuroimaging meaningfully contributes to the maintenance of brain health.
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Affiliation(s)
- Nalini M Singh
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Jordan B Harrod
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Sandya Subramanian
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Mitchell Robinson
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Ken Chang
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Suheyla Cetin-Karayumak
- Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, 02115, USA
| | | | - Simon Eickhoff
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7) Research Centre Jülich, Jülich, Germany
| | - Michael Fox
- Center for Brain Circuit Therapeutics, Department of Neurology, Psychiatry, and Radiology, Brigham and Women's Hospital and Harvard Medical School, 02115, Boston, USA
| | - Loraine Franke
- University of Massachusetts Boston, Boston, MA, 02125, USA
| | - Polina Golland
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Daniel Haehn
- University of Massachusetts Boston, Boston, MA, 02125, USA
| | - Juan Eugenio Iglesias
- Centre for Medical Image Computing, University College London, London, UK
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, 02114, USA
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Lauren J O'Donnell
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, MA, 02115, Boston, USA
| | - Yangming Ou
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Yogesh Rathi
- Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, 02115, USA
| | - Shan H Siddiqi
- Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, Boston, 02115, USA
| | - Haoqi Sun
- Department of Neurology and McCance Center for Brain Health / Harvard Medical School, Massachusetts General Hospital, Boston, 02114, USA
| | - M Brandon Westover
- Department of Neurology and McCance Center for Brain Health / Harvard Medical School, Massachusetts General Hospital, Boston, 02114, USA
| | | | - Randy L Gollub
- Department of Psychiatry and Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, 02114, USA.
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4
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Donnelly NA, Bartsch U, Moulding HA, Eaton C, Marston H, Hall JH, Hall J, Owen MJ, van den Bree MBM, Jones MW. Sleep EEG in young people with 22q11.2 deletion syndrome: A cross-sectional study of slow-waves, spindles and correlations with memory and neurodevelopmental symptoms. eLife 2022; 11:e75482. [PMID: 36039635 PMCID: PMC9477499 DOI: 10.7554/elife.75482] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 08/12/2022] [Indexed: 11/20/2022] Open
Abstract
Background Young people living with 22q11.2 Deletion Syndrome (22q11.2DS) are at increased risk of schizophrenia, intellectual disability, attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). In common with these conditions, 22q11.2DS is also associated with sleep problems. We investigated whether abnormal sleep or sleep-dependent network activity in 22q11.2DS reflects convergent, early signatures of neural circuit disruption also evident in associated neurodevelopmental conditions. Methods In a cross-sectional design, we recorded high-density sleep EEG in young people (6-20 years) with 22q11.2DS (n=28) and their unaffected siblings (n=17), quantifying associations between sleep architecture, EEG oscillations (spindles and slow waves) and psychiatric symptoms. We also measured performance on a memory task before and after sleep. Results 22q11.2DS was associated with significant alterations in sleep architecture, including a greater proportion of N3 sleep and lower proportions of N1 and REM sleep than in siblings. During sleep, deletion carriers showed broadband increases in EEG power with increased slow-wave and spindle amplitudes, increased spindle frequency and density, and stronger coupling between spindles and slow-waves. Spindle and slow-wave amplitudes correlated positively with overnight memory in controls, but negatively in 22q11.2DS. Mediation analyses indicated that genotype effects on anxiety, ADHD and ASD were partially mediated by sleep EEG measures. Conclusions This study provides a detailed description of sleep neurophysiology in 22q11.2DS, highlighting alterations in EEG signatures of sleep which have been previously linked to neurodevelopment, some of which were associated with psychiatric symptoms. Sleep EEG features may therefore reflect delayed or compromised neurodevelopmental processes in 22q11.2DS, which could inform our understanding of the neurobiology of this condition and be biomarkers for neuropsychiatric disorders. Funding This research was funded by a Lilly Innovation Fellowship Award (UB), the National Institute of Mental Health (NIMH 5UO1MH101724; MvdB), a Wellcome Trust Institutional Strategic Support Fund (ISSF) award (MvdB), the Waterloo Foundation (918-1234; MvdB), the Baily Thomas Charitable Fund (2315/1; MvdB), MRC grant Intellectual Disability and Mental Health: Assessing Genomic Impact on Neurodevelopment (IMAGINE) (MR/L011166/1; JH, MvdB and MO), MRC grant Intellectual Disability and Mental Health: Assessing Genomic Impact on Neurodevelopment 2 (IMAGINE-2) (MR/T033045/1; MvdB, JH and MO); Wellcome Trust Strategic Award 'Defining Endophenotypes From Integrated Neurosciences' Wellcome Trust (100202/Z/12/Z MO, JH). NAD was supported by a National Institute for Health Research Academic Clinical Fellowship in Mental Health and MWJ by a Wellcome Trust Senior Research Fellowship in Basic Biomedical Science (202810/Z/16/Z). CE and HAM were supported by Medical Research Council Doctoral Training Grants (C.B.E. 1644194, H.A.M MR/K501347/1). HMM and UB were employed by Eli Lilly & Co during the study; HMM is currently an employee of Boehringer Ingelheim Pharma GmbH & Co KG. The views and opinions expressed are those of the author(s), and not necessarily those of the NHS, the NIHR or the Department of Health funders.
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Affiliation(s)
- Nicholas A Donnelly
- Centre for Academic Mental Health, University of Bristol, Bristol, United Kingdom
- Avon and Wiltshire Partnership NHS Mental Health Trust, Avon, United Kingdom
| | - Ullrich Bartsch
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom
- Translational Neuroscience, Eli Lilly, Windlesham, United States
| | - Hayley A Moulding
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
| | - Christopher Eaton
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
| | - Hugh Marston
- Translational Neuroscience, Eli Lilly, Windlesham, United States
| | - Jessica H Hall
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
| | - Jeremy Hall
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
| | - Michael J Owen
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
| | - Marianne B M van den Bree
- Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
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Gombos F, Bódizs R, Pótári A, Bocskai G, Berencsi A, Szakács H, Kovács I. Topographical relocation of adolescent sleep spindles reveals a new maturational pattern in the human brain. Sci Rep 2022; 12:7023. [PMID: 35487959 PMCID: PMC9054798 DOI: 10.1038/s41598-022-11098-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/18/2022] [Indexed: 11/23/2022] Open
Abstract
Current theories of human neural development emphasize the posterior-to-anterior pattern of brain maturation. However, this scenario leaves out significant brain areas not directly involved with sensory input and behavioral control. Suggesting the relevance of cortical activity unrelated to sensory stimulation, such as sleep, we investigated adolescent transformations in the topography of sleep spindles. Sleep spindles are known to be involved in neural plasticity and in adults have a bimodal topography: slow spindles are frontally dominant, while fast spindles have a parietal/precuneal origin. The late functional segregation of the precuneus from the frontoparietal network during adolescence suggests that spindle topography might approach the adult state relatively late in development, and it may not be a result of the posterior-to-anterior maturational pattern. We analyzed the topographical distribution of spindle parameters in HD-EEG polysomnographic sleep recordings of adolescents and found that slow spindle duration maxima traveled from central to anterior brain regions, while fast spindle density, amplitude and frequency peaks traveled from central to more posterior brain regions. These results provide evidence for the gradual posteriorization of the anatomical localization of fast sleep spindles during adolescence and indicate the existence of an anterior-to-posterior pattern of human brain maturation.
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Affiliation(s)
- Ferenc Gombos
- Laboratory for Psychological Research, Pázmány Péter Catholic University, 1 Mikszáth Kálmán Sq., Budapest, 1088, Hungary.,Adolescent Development Research Group, Hungarian Academy of Sciences - Pázmány Péter Catholic University, Budapest, 1088, Hungary
| | - Róbert Bódizs
- Institute of Behavioural Sciences, Semmelweis University, Budapest, 1089, Hungary.,National Institute of Clinical Neurosciences, Budapest, 1145, Hungary
| | - Adrián Pótári
- Adolescent Development Research Group, Hungarian Academy of Sciences - Pázmány Péter Catholic University, Budapest, 1088, Hungary
| | - Gábor Bocskai
- Laboratory for Psychological Research, Pázmány Péter Catholic University, 1 Mikszáth Kálmán Sq., Budapest, 1088, Hungary.,Doctoral School of Mental Health Sciences, Semmelweis University, Üllői st. 26, Budapest, 1085, Hungary
| | - Andrea Berencsi
- Adolescent Development Research Group, Hungarian Academy of Sciences - Pázmány Péter Catholic University, Budapest, 1088, Hungary.,Institute for the Methodology of Special Needs Education and Rehabilitation, Bárczi Gusztáv Faculty of Special Needs Education, Eötvös Loránd University, Budapest, 1097, Hungary
| | - Hanna Szakács
- Laboratory for Psychological Research, Pázmány Péter Catholic University, 1 Mikszáth Kálmán Sq., Budapest, 1088, Hungary.,Doctoral School of Mental Health Sciences, Semmelweis University, Üllői st. 26, Budapest, 1085, Hungary
| | - Ilona Kovács
- Laboratory for Psychological Research, Pázmány Péter Catholic University, 1 Mikszáth Kálmán Sq., Budapest, 1088, Hungary. .,Adolescent Development Research Group, Hungarian Academy of Sciences - Pázmány Péter Catholic University, Budapest, 1088, Hungary. .,Institute of Cognitive Neuroscience and Psychology, Research Centre for Natural Sciences, Budapest, 1117, Hungary.
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6
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Association of polygenic risk for schizophrenia with fast sleep spindle density depends on pro-cognitive variants. Eur Arch Psychiatry Clin Neurosci 2022; 272:1193-1203. [PMID: 35723738 PMCID: PMC9508216 DOI: 10.1007/s00406-022-01435-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/15/2022] [Indexed: 11/14/2022]
Abstract
Cognitive impairment is a common feature in schizophrenia and the strongest prognostic factor for long-term outcome. Identifying a trait associated with the genetic background for cognitive outcome in schizophrenia may aid in a deeper understanding of clinical disease subtypes. Fast sleep spindles may represent such a biomarker as they are strongly genetically determined, associated with cognitive functioning and impaired in schizophrenia and unaffected relatives. We measured fast sleep spindle density in 150 healthy adults and investigated its association with a genome-wide polygenic score for schizophrenia (SCZ-PGS). The association between SCZ-PGS and fast spindle density was further characterized by stratifying it to the genetic background of intelligence. SCZ-PGS was positively associated with fast spindle density. This association mainly depended on pro-cognitive genetic variants. Our results strengthen the evidence for a genetic background of spindle abnormalities in schizophrenia. Spindle density might represent an easily accessible marker for a favourable cognitive outcome which should be further investigated in clinical samples.
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7
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Bartsch U, Corbin LJ, Hellmich C, Taylor M, Easey KE, Durant C, Marston HM, Timpson NJ, Jones MW. Schizophrenia-associated variation at ZNF804A correlates with altered experience-dependent dynamics of sleep slow waves and spindles in healthy young adults. Sleep 2021; 44:zsab191. [PMID: 34329479 PMCID: PMC8664578 DOI: 10.1093/sleep/zsab191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/06/2021] [Indexed: 12/12/2022] Open
Abstract
The rs1344706 polymorphism in ZNF804A is robustly associated with schizophrenia and schizophrenia is, in turn, associated with abnormal non-rapid eye movement (NREM) sleep neurophysiology. To examine whether rs1344706 is associated with intermediate neurophysiological traits in the absence of disease, we assessed the relationship between genotype, sleep neurophysiology, and sleep-dependent memory consolidation in healthy participants. We recruited healthy adult males with no history of psychiatric disorder from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Participants were homozygous for either the schizophrenia-associated 'A' allele (N = 22) or the alternative 'C' allele (N = 18) at rs1344706. Actigraphy, polysomnography (PSG) and a motor sequence task (MST) were used to characterize daily activity patterns, sleep neurophysiology and sleep-dependent memory consolidation. Average MST learning and sleep-dependent performance improvements were similar across genotype groups, albeit more variable in the AA group. During sleep after learning, CC participants showed increased slow-wave (SW) and spindle amplitudes, plus augmented coupling of SW activity across recording electrodes. SW and spindles in those with the AA genotype were insensitive to learning, whilst SW coherence decreased following MST training. Accordingly, NREM neurophysiology robustly predicted the degree of overnight motor memory consolidation in CC carriers, but not in AA carriers. We describe evidence that rs1344706 polymorphism in ZNF804A is associated with changes in the coordinated neural network activity that supports offline information processing during sleep in a healthy population. These findings highlight the utility of sleep neurophysiology in mapping the impacts of schizophrenia-associated common genetic variants on neural circuit oscillations and function.
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Affiliation(s)
- Ullrich Bartsch
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
- Translational Neuroscience, Eli Lilly & Co Ltd UK, Erl Wood Manor, Windlesham, UK
- UK DRI Health Care & Technology at Imperial College London and the University of Surrey, Surrey Sleep Research Centre, University of Surrey, Clinical Research Building, Egerton Road, Guildford, Surrey, UK
| | - Laura J Corbin
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Charlotte Hellmich
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| | - Michelle Taylor
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
| | - Kayleigh E Easey
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
- UK Centre for Tobacco and Alcohol Studies, School of Psychological Science, University of Bristol, Bristol, UK
| | - Claire Durant
- Clinical Research and Imaging Centre (CRIC), University of Bristol, Bristol, UK
| | - Hugh M Marston
- Translational Neuroscience, Eli Lilly & Co Ltd UK, Erl Wood Manor, Windlesham, UK
- Böhringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Nicholas J Timpson
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew W Jones
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
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8
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Fekih-Romdhane F, Nefzi H, Sassi H, Cherif W, Cheour M. Sleep in first-episode schizophrenia patients, their unaffected siblings and healthy controls: A comparison. Early Interv Psychiatry 2021; 15:1167-1178. [PMID: 33037776 DOI: 10.1111/eip.13058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/04/2020] [Accepted: 09/26/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sleep disturbances in schizophrenia are common throughout its course including in the prodrome, and have been mainly attributed to severity of symptoms and antipsychotic use. We aimed to investigate whether early course patients with schizophrenia and young non-psychotic siblings of patients with schizophrenia also show sleep disturbances and whether sleep correlates with symptoms and functioning. METHODS Three study groups, that is, adults newly diagnosed with schizophrenia (n = 54), young non-psychotic siblings of schizophrenia patients (n = 56) and a sample of healthy controls matched to the patients and siblings (n = 61) were evaluated on Horne and Ostberg Morningness-Eveningness Questionnaire, Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index. Severity of symptoms and functioning are assessed using the Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale, respectively. Age, gender, occupation and marital status were regarded as covariates, and differences between the three groups were evaluated using analysis of covariance. RESULTS Early course schizophrenia patients and non-psychotic siblings of schizophrenia patients showed significantly reduced sleep quality relative to healthy controls (P < .001). Schizophrenia patients had significantly higher daytime sleepiness compared to controls (P < .001). Chronotypes in schizophrenia patients and unaffected siblings did not significantly differ from those of the healthy controls. CONCLUSIONS Like chronic medicated schizophrenia patients, early course schizophrenia patients and young non-psychotic siblings of individuals with schizophrenia have sleep disturbances. These findings indicate that sleep markers can distinguish unaffected siblings of schizophrenia from healthy controls and serve as an endophenotype for schizophrenia.
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Affiliation(s)
- Feten Fekih-Romdhane
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Department of psychiatry "Ibn Omrane", Razi Hospital, Mannouba, Tunisia
| | - Houssem Nefzi
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Department of psychiatry "Ibn Omrane", Razi Hospital, Mannouba, Tunisia
| | - Hadhami Sassi
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Department of psychiatry "Ibn Omrane", Razi Hospital, Mannouba, Tunisia
| | - Wissal Cherif
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Department of psychiatry "Ibn Omrane", Razi Hospital, Mannouba, Tunisia
| | - Majda Cheour
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Department of psychiatry "Ibn Omrane", Razi Hospital, Mannouba, Tunisia
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9
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Ranjan R, Chandra Sahana B, Kumar Bhandari A. Ocular artifact elimination from electroencephalography signals: A systematic review. Biocybern Biomed Eng 2021. [DOI: 10.1016/j.bbe.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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10
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Gisabella B, Babu J, Valeri J, Rexrode L, Pantazopoulos H. Sleep and Memory Consolidation Dysfunction in Psychiatric Disorders: Evidence for the Involvement of Extracellular Matrix Molecules. Front Neurosci 2021; 15:646678. [PMID: 34054408 PMCID: PMC8160443 DOI: 10.3389/fnins.2021.646678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/22/2021] [Indexed: 12/13/2022] Open
Abstract
Sleep disturbances and memory dysfunction are key characteristics across psychiatric disorders. Recent advances have revealed insight into the role of sleep in memory consolidation, pointing to key overlap between memory consolidation processes and structural and molecular abnormalities in psychiatric disorders. Ongoing research regarding the molecular mechanisms involved in memory consolidation has the potential to identify therapeutic targets for memory dysfunction in psychiatric disorders and aging. Recent evidence from our group and others points to extracellular matrix molecules, including chondroitin sulfate proteoglycans and their endogenous proteases, as molecules that may underlie synaptic dysfunction in psychiatric disorders and memory consolidation during sleep. These molecules may provide a therapeutic targets for decreasing strength of reward memories in addiction and traumatic memories in PTSD, as well as restoring deficits in memory consolidation in schizophrenia and aging. We review the evidence for sleep and memory consolidation dysfunction in psychiatric disorders and aging in the context of current evidence pointing to the involvement of extracellular matrix molecules in these processes.
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Affiliation(s)
| | | | | | | | - Harry Pantazopoulos
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, MS, United States
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11
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Pesonen AK, Merikanto I, Halonen R, Ujma P, Makkonen T, Räikkönen K, Lahti J, Kuula L. Polygenic impact of morningness on the overnight dynamics of sleep spindle amplitude. GENES BRAIN AND BEHAVIOR 2020; 19:e12641. [PMID: 31925898 DOI: 10.1111/gbb.12641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 12/18/2019] [Accepted: 01/07/2020] [Indexed: 11/28/2022]
Abstract
Sleep spindles are thalamocortical oscillations that contribute to sleep maintenance and sleep-related brain plasticity. The current study is an explorative study of the circadian dynamics of sleep spindles in relation to a polygenic score (PGS) for circadian preference towards morningness. The participants represent the 17-year follow-up of a birth cohort having both genome-wide data and an ambulatory sleep electroencephalography measurement available ( N = 154, Mean age = 16.9, SD = 0.1 years, 57% girls). Based on a recent genome-wide association study, we calculated a PGS for circadian preference towards morningness across the whole genome, including 354 single-nucleotide polymorphisms. Stage 2 slow (9-12.5 Hz, N = 186 739) and fast (12.5-16 Hz, N = 135 504) sleep spindles were detected using an automated algorithm with individual time tags and amplitudes for each spindle. There was a significant interaction of PGS for morningness and timing of sleep spindles across the night. These growth curve models showed a curvilinear trajectory of spindle amplitudes: those with a higher PGS for morningness showed higher slow spindle amplitudes in frontal derivations, and a faster dissipation of spindle amplitude in central derivations. Overall, the findings provide new evidence on how individual sleep spindle trajectories are influenced by genetic factors associated with circadian type. The finding may lead to new hypotheses on the associations previously observed between circadian types, psychiatric problems and spindle activity.
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Affiliation(s)
- Anu-Katriina Pesonen
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ilona Merikanto
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,National Institute for Health and Welfare, Helsinki, Finland
| | - Risto Halonen
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Peter Ujma
- Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary.,Epilepsy Centre, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Tommi Makkonen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Katri Räikkönen
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Lahti
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Liisa Kuula
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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12
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Kaskie RE, Ferrarelli F. Sleep disturbances in schizophrenia: what we know, what still needs to be done. Curr Opin Psychol 2019; 34:68-71. [PMID: 31671368 DOI: 10.1016/j.copsyc.2019.09.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/31/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Sleep disturbances are commonly observed in schizophrenia (SCZ) and are associated with worse psychotic symptoms and poorer clinical outcomes. Early polysomnography studies have focused on characterizing differences in sleep architecture between patients with SCZ and healthy controls. More recently, research has focused on sleep-specific EEG oscillations, such as sleep spindles and slow waves, which reflect the integrity of underlying thalamo-cortical networks. Furthermore, high-density (hd)-EEG (≥64 channels), which affords enhanced spatial resolution, has been employed to better localize abnormalities in sleep characteristics and related thalamo-cortical circuits in patients with SCZ and related disorders. In this article, we will review the most relevant sleep abnormalities reported in SCZ, with an emphasis on recent findings, and propose directions for future research.
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13
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Andrade A, Brennecke A, Mallat S, Brown J, Gomez-Rivadeneira J, Czepiel N, Londrigan L. Genetic Associations between Voltage-Gated Calcium Channels and Psychiatric Disorders. Int J Mol Sci 2019; 20:E3537. [PMID: 31331039 PMCID: PMC6679227 DOI: 10.3390/ijms20143537] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/12/2019] [Accepted: 07/13/2019] [Indexed: 12/23/2022] Open
Abstract
Psychiatric disorders are mental, behavioral or emotional disorders. These conditions are prevalent, one in four adults suffer from any type of psychiatric disorders world-wide. It has always been observed that psychiatric disorders have a genetic component, however, new methods to sequence full genomes of large cohorts have identified with high precision genetic risk loci for these conditions. Psychiatric disorders include, but are not limited to, bipolar disorder, schizophrenia, autism spectrum disorder, anxiety disorders, major depressive disorder, and attention-deficit and hyperactivity disorder. Several risk loci for psychiatric disorders fall within genes that encode for voltage-gated calcium channels (CaVs). Calcium entering through CaVs is crucial for multiple neuronal processes. In this review, we will summarize recent findings that link CaVs and their auxiliary subunits to psychiatric disorders. First, we will provide a general overview of CaVs structure, classification, function, expression and pharmacology. Next, we will summarize tools to study risk loci associated with psychiatric disorders. We will examine functional studies of risk variations in CaV genes when available. Finally, we will review pharmacological evidence of the use of CaV modulators to treat psychiatric disorders. Our review will be of interest for those studying pathophysiological aspects of CaVs.
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Affiliation(s)
- Arturo Andrade
- Department of Biological Sciences, University of New Hampshire, Durham, NH 03824, USA.
| | - Ashton Brennecke
- Department of Biological Sciences, University of New Hampshire, Durham, NH 03824, USA
| | - Shayna Mallat
- Department of Biological Sciences, University of New Hampshire, Durham, NH 03824, USA
| | - Julian Brown
- Department of Biological Sciences, University of New Hampshire, Durham, NH 03824, USA
| | | | - Natalie Czepiel
- Department of Biological Sciences, University of New Hampshire, Durham, NH 03824, USA
| | - Laura Londrigan
- Department of Biological Sciences, University of New Hampshire, Durham, NH 03824, USA
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14
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Merikanto I, Kuula L, Makkonen T, Salmela L, Räikkönen K, Pesonen AK. Autistic Traits Are Associated With Decreased Activity of Fast Sleep Spindles During Adolescence. J Clin Sleep Med 2019; 15:401-407. [PMID: 30853050 DOI: 10.5664/jcsm.7662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/26/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Autistic traits present a continuum from mild symptoms to severe disorder and have been associated with a high prevalence of sleep problems. Sleep spindles have a key function in sleep maintenance and in brain plasticity. Previous studies have found decreased spindle activity in clinical autism. Here we examine the associations between the entire range of autistic traits and sleep spindle activity in a nonclinical community cohort of adolescents. METHODS Our cohort is based on 172 adolescents born in 1998 (58.7% girls, mean age = 16.9 years, standard deviation = 0.1), who filled in the adult autism-spectrum quotient (AQ), consisting of total score, and social interaction and attention to details subscales. Participants underwent an ambulatory overnight sleep electroencephalography. Sleep spindles (amplitude, duration, density, and intensity) were automatically detected from stage N2 sleep, and divided to slow and fast spindles. RESULTS Higher AQ total sum and social interaction sum associated with lower fast spindle amplitude and intensity (P < .04). No associations were observed for attention to details. CONCLUSIONS Our findings indicate that a higher level of autistic traits in the nonclinical range among generally healthy adolescents associate with similar alterations in sleep spindle activity as observed in many neuropsychiatric conditions, indicating lower sleep-related brain plasticity. This indicates that sleep microstructures form a continuum that follows self-reported symptoms of autism.
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Affiliation(s)
- Ilona Merikanto
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,National Institute for Health and Welfare, Helsinki, Finland.,Orton Orthopaedics Hospital, Helsinki, Finland
| | - Liisa Kuula
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tommi Makkonen
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Liisa Salmela
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Katri Räikkönen
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Anu-Katriina Pesonen
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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