Targeted bisulfite sequencing: A novel tool for the assessment of DNA methylation with high sensitivity and increased coverage

DNA methylation analysis is increasingly used in stress research. Available methods are expensive, laborious and often limited by either the analysis of short CpG stretches or low assay sensitivity. Here, we present a cost-efficient next generation sequencing-based strategy for the simultaneous investigation of multiple candidate genes in large cohorts. To illustrate the method, we present analysis of four candidate genes commonly assessed in psychoneuroendocrine research: Glucocorticoid receptor (NR3C1), Serotonin transporter (SLC6A4), FKBP Prolyl isomerase 5 (FKBP5), and the Oxytocin receptor (OXTR). DNA methylation standards (100 %; 75 %; 50 %; 25 % and 0 %) and DNA of a female and male donor were bisulfite treated in three independent trials and were used to generate sequencing libraries for 42 CpGs from the NR3C1 1 F promoter region, 84 CpGs of the SLC6A4 5' regulatory region, 5 CpGs located in FKBP5 intron 7, and additional 12 CpGs located in a potential enhancer element in intron 3 of the OXTR. In addition, DNA of 45 patients with borderline personality disorder (BPD) and 45 healthy controls was assayed. Multiplex libraries of all samples were sequenced on a MiSeq system and analyzed for mean methylation values of all CpG sites using amplikyzer2 software. Results indicated excellent accuracy of the assays when investigating replicates generated from the same bisulfite converted DNA, and very high linearity (R² > 0.9) of the assays shown by the analysis of differentially methylated DNA standards. Comparing DNA methylation between BPD and healthy controls revealed no biologically relevant differences. The technical approach as described here facilitates targeted DNA methylation analysis and represents a highly sensitive, cost-efficient and high throughput tool to close the gap between coverage and precision in epigenetic research of stress-associated phenotypes.

Early Multidisciplinary Intensive-care Therapy can Improve Outcome of Severe Anti-NMDA-receptor Encephalitis Presenting with Extreme Delta Brush

Anti-N-methyl-D-aspartate receptor encephalitis (Anti-NMDARE) is a synaptic autoimmune encephalitis syndrome mainly affecting young females. An underlying tumor, most commonly ovarian teratomas in young females, may indicate a paraneoplastic syndrome. Prognostic factors of the clinical course of disease and outcome play a central role in view of early administration of second-line immunotherapy and intensive-care therapy. We report a case of severe Anti-NMDARE associated with unfavorable predictors including an extreme delta brush (EDB) electroencephalographic-pattern and high anti-NMDAR-antibody titers in the cerebral spinal fluid (CSF), which necessitated the admission to an intensive care unit. In spite of the poor prognosis, the patient completely recovered; we attribute this to an early escalation to second-line immunotherapy with rituximab and multidisciplinary intensive-care therapy. The present case underlines the relevance of multidisciplinary management for individuals with Anti-NMDARE.

[Social psychiatry and neurobiology : A long overdue convergence exemplified by schizophrenia]

BACKGROUND

The proliferation of biological psychiatry has greatly increased over the last two decades. With the possibility to carry out brain research using modern technical methods, it seemed that social influencing factors would lose importance in the development of mental diseases; however, in actual fact this does not seem to be justified. It is necessary to overcome this separation, in that social factors are incorporated into a conceptual framework in the development of mental diseases, which simultaneously also takes the results of current neurobiological research into consideration.

OBJECTIVES AND METHODS

The aims of this review article are to summarize the current state of sociopsychiatric research and to emphasize the perspectives of the biological principles and their validity with respect to the social dimensions of psychiatry, as exemplified by schizophrenic disorders. The article presents the options for a biosocial approach in social psychiatry and gives an overview of the currently available literature.

RESULTS AND CONCLUSION

There is an abundance of neurobiological research approaches, which are closely associated with sociopsychiatric topics, such as social cognition. Social psychiatry and biological psychiatry should no longer be considered as diametrically opposed subdisciplines. On the contrary, the options which could emerge from a synthesis must be used in research and clinical practice.

Direct costs in impaired glucose regulation: results from the population-based Heinz Nixdorf Recall study

OBJECTIVE

For the first time, this population-based study sought to analyze healthcare utilization and associated costs in people with normal fasting glycemia (NFG), impaired fasting glycemia (IFG), as well as previously undetected diabetes and previously diagnosed diabetes linking data from the prospective German Heinz Nixdorf Recall (HNR) study with individual claims data from German statutory health insurances.

RESEARCH DESIGN AND METHODS

A total of 1709 participants of the HNR 5-year follow-up (mean age (SD) 64.9 (7.5) years, 44.5% men) were included in the study. Age-standardized and sex-standardized healthcare utilization and associated costs (reported as € for the year 2008, perspective of the statutory health insurance) were stratified by diabetes stage defined by the participants' self-report and fasting plasma glucose values. Cost ratios (CRs) were estimated using two-part regression models, adjusting for age, sex, sociodemographic variables and comorbidity.

RESULTS

The mean total direct healthcare costs for previously diagnosed diabetes, previously undetected diabetes, IFG, and NFG were €2761 (95% CI 2378 to 3268), €2210 (1483 to 4279), €2035 (1732 to 2486) and €1810 (1634 to 2035), respectively. Corresponding age-adjusted and sex-adjusted CRs were 1.53 (1.30 to 1.80), 1.16 (0.91 to 1.47), and 1.09 (0.95 to 1.25) (reference: NFG). Inpatient, outpatient and medication costs varied in order between people with IFG and those with previously undetected diabetes.

CONCLUSIONS

The study provides claims-based detailed cost data in well-defined glucose metabolism subgroups. CRs of individuals with IFG and previously undetected diabetes were surprisingly low. Data are important for the model-based evaluation of screening programs and interventions that are aimed either to prevent diabetes onset or to improve diabetes therapy as well.

Improving social perception in schizophrenia: the role of oxytocin

Previous research has shown that patients with schizophrenia are impaired in a wide range of social cognitive abilities, including emotion recognition, empathy for others, and mental perspective-taking. Recent studies suggest that a dysfunction of the oxytocinergic system contributes to the social impairment in schizophrenia. Accordingly, the present study sought to examine whether patients with schizophrenia would improve in a social perception task after taking a single dose of oxytocin, as compared to a placebo. Thirty-five patients diagnosed with schizophrenia were compared with 46 psychologically healthy matched controls on their recognition of kinship and intimacy, using the Interpersonal Perception Task. All participants received a single intranasal dose of 24 IU oxytocin or placebo, one week apart. Overall, the participants were more accurate in judging intimacy and kinship following the administration of oxytocin, as opposed to a placebo. However, when comparing patients with controls, only the recognition of kinship improved significantly in the patient group, whereas no such effect was observed in the control group or in the recognition of intimacy in either group. This is one of the first studies to demonstrate that social perception in schizophrenia can be improved by the administration of oxytocin and that patients show a greater treatment effect than controls.

Mental state attribution in schizophrenia: what distinguishes patients with "poor" from patients with "fair" mentalising skills?

PURPOSE

Although many patients with schizophrenia are impaired in mental states attribution abilities, a significant number perform within normal or near-normal ranges in mental state attribution tasks. No studies have analysed cognitive or behavioural differences between patients with - to some extent - preserved mental state attribution skills and those with poor mentalising abilities.

MATERIAL AND METHODS

To examine characteristics of "poor" and "fair" mentalisers, 58 patients with schizophrenia performed a mental state attribution task, a test of general intelligence, and two executive functioning tests. "Poor" and "fair" mentalising skills were defined according to a median-split procedure; the median score in the patient group was also within two standard deviations of the control group. In addition, patients' social behavioural skills and psychopathological profiles were rated.

RESULTS

Patients performing within normal or near normal ranges on the mental state attribution task had fewer social behavioural abnormalities than patients with poor mentalising abilities (even when controlled for intelligence), but did not differ in executive functioning. Fair mental state performers showed less disorganisation and excitement symptoms than poor performers. The degree of disorganisation mediated the influence of mental state attribution on social behavioural skills.

CONCLUSIONS

Schizophrenia patients with (partially) preserved mentalising skills have fewer behavioural problems in the social domain than patients with poor mentalising abilities. Conceptual disorganisation mediates the prediction of social behavioural skills through mentalising skills, suggesting that disorganised patients may require special attention regarding social-cognitive skills training.

Alexithymia, emotion processing and social anxiety in adults with ADHD

Objective

Given sparse research on the issue, this study sought to shed light upon the interactions of alexithymia, emotion processing, and social anxiety in adults with attention-deficit hyperactivity disorder (ADHD).

Subjects and methods

73 German adults with ADHD according to DSM-IV diagnostic criteria participated. We used the Toronto Alexithymia Scale (TAS-20) to assess alexithymia, the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) to assess different features of social anxiety, and we applied the German 'Experience of Emotions Scale' (SEE) to measure emotion processing.

Results

40% of the sample were found to meet the DSM-IV criteria of social anxiety disorder, and about 22% were highly alexithymic according to a TAS-20 total score ≥ 61; however, the mean TAS-20 total score of 50.94 ± 9.3 was not much higher than in community samples. Alexithymic traits emerged to be closely linked to emotion processing problems, particularly 'difficulty accepting own emotions', and to social anxiety features.

Discussion/conclusion

Our findings suggest interactions of alexithymia, emotion processing dysfunction, and social anxiety in adults with ADHD, which may entail the therapeutic implication to thoroughly instruct these patients to identify, accept, communicate, and regulate their emotions to aid reducing interaction anxiety.

[Theory of mind in schizophrenia: clinical aspects and empirical research]

The term Theory of Mind (ToM) refers to the capacity to infer one's own and other persons' mental states. A substantial body of research has highlighted impaired ToM in a variety of neuropsychiatric disorders, including schizophrenia. There is good empirical evidence that ToM is specifically impaired in schizophrenia and that many psychotic symptoms--for instance, delusions of alien control and persecution--may best be understood in light of a disturbed capacity in patients to relate their own intentions to executing behavior, and to monitor others' intentions. However, it is still under debate if impaired ToM in schizophrenia is a state- or trait marker and whether patients could benefit from cognitive training in this domain. Recently, research has not only emphasized social cognitive deficits in patients, but has also focussed on interactions between ToM with language and other cognitive functions. Furthermore, interest in subprocesses of social cognition in psychotic spectrum disorders (e. g. schizotypy) is growing. The aim of this article is to line out clinical aspects of disturbed social cognition, to clarify terms used in this context as well as to present the latest research approaches into social cognition deficits.

[An unusual case of anterior communicating artery syndrome]

We describe the case of a 51-year-old man who developed acute partial anterior communicating artery syndrome (ACoAS) due to a nonruptured aneurysm of that artery. The patient presented with anterograde memory deficits, particularly impaired delayed recall, whereas his declarative learning and retrograde memory were relatively spared. Full ACoAS is usually associated with confabulations and personality change, which did not present in the case reported here. However, the patient presented with the flat affect and reduced drive typical of frontal lobe disorder. Clinical and neuropsychological assessment largely ruled out other causal factors involved in the symptomatology. Upon follow-up 2 years after onset of the AcoAS, the patient's neuropsychological performance had remained stable, yet his affective resonance and, in part, his spatial orientation had improved. We conclude that malformations of the intracranial arterial system ought to be taken into account as differential diagnosis of acute memory disorders.

Neuropsychologische Aspekte wahnhafter Störungen

BACKGROUND

"Pure" delusional disorders are clinically rare, and the neuropsychology of such disorders is poorly understood. Whereas "deficit" models suggest a cognitive impairment accounting for the incorrigible fixation of false beliefs, cognitive models propose the existence of a characteristic attributional style in patients to stabilise a fragile self.

PATIENTS AND METHODS

The cognitive flexibility and attributional style of 21 patients diagnosed with delusional disorder according to ICD-10 were compared with a group of healthy controls paralleled for age, sex, education, and intelligence.

RESULTS

Patients with delusional disorders made more errors and more perseverative errors in the Wisconsin Card Sorting Test compared with controls. However, these differences were only significant in patients with a comorbid depression. In contrast to earlier studies, patients with delusional disorders did not attribute negative events to external or personal causes more often than healthy controls, but partly tended to show a depressive attributional style.

CONCLUSION

Our results do not support either a cognitive deficit in patients with delusional disorders or a characteristic attributional style. In terms of treatment recommendations, a thorough diagnosis of comorbid depressive disorders in patients with delusional disorders is warranted.

[A case of primary zopiclone dependence]

MEDICAL HISTORY

A 59-year-old female patient reported an increasing intake of up to 20 pills of zopiclone per day (150 mg) during the past 3 years. The dose increase was associated with euphoria and subjectively improved fitness. The patient suffered from anxiety and inner restlessness when trying to discontinue the medication, as well as from fatigue and forgetfulness when on medication. The medical history was free of psychiatric disorders and abuse of psychoactive substances.

CLINICAL FINDINGS

Apart from mild attention and concentration deficits with a mildly depressed mood the psychiatric findings were normal.

COURSE AND TREATMENT

Consistent with the preliminary diagnosis of a primary non-benzodiazepine dependence (zopiclone), after withdrawal of zopiclone the patient suffered from inner restlessness and psychomotor agitation, vague abdominal pain, and hypertension. The symptoms subsided after administration and subsequent gradual discontinuation of diazepam.

CONCLUSION

Zopiclone dependence has repeatedly been reported in patients with pre-existing substance-related addictions, and in patients with other psychiatric disorders. Primary zopiclone dependence may be regarded as rare. Despite the low dependence potential of non-benzodiazepine hypnotics, the indication of prescription should be thoroughly considered.

[Neuropsychological follow-up of attention deficit/hyperactive disorder in adulthood before and after treatment with methylphenidate]

Attention-deficit/hyperactivity disorder (ADHD) in adulthood is frequently overlooked. Motor restlessness, impulsivity, low frustration tolerance, and conduct disorders are diagnostically ambiguous, but are predominantly ascribed to affective disorders, anxiety disorders, and personality disorders. Furthermore, substance-induced addiction may develop consecutively to untreated ADHD. We report on a case of primary diagnosis of ADHD in adulthood with secondary cocaine dependency, who was neuropsychologically assessed before and following treatment with methylphenidate. Frequency of errors and reaction time in performance on attention tests, concentration tasks, and multiple stimuli-/reaction tasks improved under treatment with methylphenidate. ADHD may be treated efficiently even after primary diagnosis in adulthood. Differential diagnosis of ADHD should be considered in disorders associated with motor hyperactivity, impulsivity, stress intolerance and conduct disorders.

[A case of delusional jealousy in Parkinson disease ]

Delusional jealousy has been reported in organic and "functional" psychotic disorders. In organic psychoses, delusional jealousy is usually associated with impaired orientation or other cognitive disturbances. Delusional jealousy in Parkinson's disease has rarely been reported in the scientific literature. A case of a 49-year-old man suffering from this pathology in the course of Parkinson's disease is presented as to clinical picture, therapy, course, and outcome.

Social cognition and psychopathology in an evolutionary perspective. Current status and proposals for research

The phylogenetic and ontogenetic developments of social cognition have been a major research focus of evolutionary and developmental psychology. Theory of mind or so-called Machiavellian intelligence, that is the capacity to infer mental states of other individuals and to manipulate them in order to maximise social success, probably emerged due to the need to cope with an increasingly complex social environment. Studies on social reasoning suggest disturbances of mental state attribution in psychiatric disorders. However, apart from autism spectrum disorders, the systematic evaluation of social cognition is still in its infancy, and the present data are ambiguous due to methodological difficulties. Based on the concept of the modular organisation of the mind, a stepwise investigation of social cognition in psychiatric disorders is proposed, including clinical description and available standardised methods. The specific characteristics of psychiatric disorders in respect of social cognition, therefore, may vary according to the hierarchical organisation of the social module. Systematic studies on social reasoning processes in psychiatric disorders may provide new insights also useful for the development of coping strategies in cognitive-behavioural therapy.

Evolutionary fallacies of Nazi psychiatry. Implications for current research

Evolutionary theory has had a major impact on psychiatry since the middle of the 19th century. During the Nazi regime psychiatry supported compulsory sterilization and euthanasia of physically and mentally ill and subsequently the killing of "inferior" races by borrowing scientifically invalid conclusions from evolutionary biology. The present paper deals with some of the flaws and shortcomings of the scientific paradigms of evolutionary theory adopted by psychiatry during the Nazi regime and discusses possible implications for modern research in evolutionary psychology and psychiatry.

Animal models of acute drug-induced akathisia - a review

Akathisia is a complex neurobehavioural side effect of neuroleptics and some other drugs which is characterised by subjective report and objective manifestations of restlessness. Its pathophysiology is poorly understood and there are many limitations to its investigation in humans. This paper reviews the various attempts that have been made in modelling acute akathisia in animals. Homologous as well as isomorphic models have been attempted, but most models are partial as they reproduce either the subjective or the objective features of the syndrome. None of the available models has been fully validated. Neuroleptic-induced defecation in the rat, even though constrained by a lack of symptom similarity and thereby face validity, has been most studied as a model of subjective akathisia. Rat models of restlessness, in particular those involving the use of serotonergic drugs or lesions of the ventral tegmentum or medial prefrontal cortex, are interesting partial models that should be further investigated. Neuroleptic-induced akathisia is observed in primates and has been modelled in dogs, and these should be studied further for their validation. It is also necessary to consider the subtypes of akathisia in the attempts to develop these models.

The incidence of akathisia in bipolar affective disorder treated with neuroleptics--a preliminary report

BACKGROUND

Akathisia is a common side effect of neuroleptic therapy. Prevalence and incidence studies of akathisia have been predominantly undertaken in patients with schizophrenia and schizoaffective disorder. Investigations of akathisia in neuroleptic treated patients suffering from bipolar disorder are lacking.

METHOD

In the present study, 23 patients with bipolar affective disorder who were treated with neuroleptics were assessed for akathisia and parkinsonism, using the Barnes Akathisia Rating Scale and DSM-IV criteria, respectively.

RESULTS

15 patients (65.2%) developed akathisia. Eighteen patients (78.3%) had parkinsonism, including all of the akathisia-group. In six patients (40%) of the akathisia-group the onset of akathisia was after neuroleptic dose reduction or after additional administration of mood stabilizers.

CONCLUSIONS

Neuroleptic-induced side effects may occur frequently in patients with bipolar affective disorder and should therefore be monitored thoroughly. Demasking effects due to diminishing parkinsonian symptoms may contribute to akathisia-onset after neuroleptic dose reduction. Early application of alternative treatment regimens, e.g. monotherapy with mood stabilizers in combination with benzodiazepines should be considered.

FUTURE DIRECTIONS

The preliminary findings require further investigation regarding dose dependency, incidence of akathisia in untreated patients with bipolar affective disorder, akathisia in patients with depressed episodes on SSRI, and possible differences between various mood stabilizers in their propensity to enhance akathisia, as well as possible sex differences.

[Stability and variability of catatonic symptoms in the longitudinal course of illness. Videotape documentation in catatonic schizophrenia]

The symptomatology of a female patient with catatonic schizophrenia is presented with respect to its longitudinal course. The stability and variability of catatonic symptoms are investigated using videotape technique. It is demonstrated that catatonic symptoms are stable in the longitudinal course but due to unsteady arousal the severity of the catatonic symptoms varies markedly. There are fluctuating symptom patterns that dominate the clinical picture: a hyperkinetic form with prevailing restlessness or excitement, with abnormal involuntary movements, stereotypies, and parakinetic movements, and a hypokinetic form with various inhibition phenomena, mutism and stupor. The clinical impression of the catatonic syndrome changes according to the dominating symptom patterns at different times, whereas the less severe symptoms recede into the background and thus, may be overlooked. Considering this finding the problem of a 'diagnostic threshold' is discussed. The authors intend to emphasize videotape documentation of catatonic motor disturbances as most useful. This technique may contribute to differentiating illness related from neuroleptic induced movement disorders.

[The relevance of ethology for psychiatry]

Darwin's evolutionary theory was the starting point for ethology, associated with an impact on scientific psychiatry. Psychiatry and ethology have common scientific and methodological prerequisites: inductive and deductive methods and "gestalt theory" as a basis for observing and describing behaviour patterns with subsequent causal analysis. There have been early endeavours to anchor ethological thinking in psychiatry but this tendency did not prevail for the following reasons: on the one hand, the methodology of ethology was immature or not applicable to man, whereas on the other hand the dominating experiential phenomenological school of Karl Jaspers and Kurt Schneider stressed the privileged position of human thinking, perception, and feeling. These fundamental categories of human existence did not appear amenable to any causal ethological analysis. Psychiatry and evolutionary biology were linked in an atrocious manner during the Nazi regime, both being abused for propaganda purposes and genocide. More recently, there is a "reconciliation" of both disciplines. In psychiatric nosology, operational, behaviour-oriented diagnostic systems have been introduced; ethology has opened up for theories of learning; new subsections like human ethology and sociobiology have evolved. The seeming incompatibility of (behavioural) biological psychiatry and experiential phenomenological psychopathology may be overcome on the basis of Konrad Lorenz' evolutionary epistemology. The functional analysis of human feeling and behaviour in psychotic disorders on the basis of Jackson's theory of the evolution and dissolution of the nervous system may serve as an example. The significance of an "ethological psychiatry" for diagnostic and therapeutical processes of psychiatric disorders derive from prognostic possibilities and the analysis of non-verbal communication in therapist-patient-interactions, but have not yet been systematically investigated.

Ethological remarks on mannerisms. Conceptualisation and proposal for a definition. off

Mannerisms are symptoms of various psychiatric disorders. The term has not been defined thoroughly and is often confused with stereotypies or the more generally used term 'bizarreness'. From an ethological perspective, mannerisms may be regarded as pathologically altered forms of ritualised behaviour that serve a communicative purpose. Mannerisms are maladaptive behaviours since they lead to withdrawal of and rejection by the socially interacting partner, or even induce aggressive behaviour due to the pathologically exaggerated and overdrawn appearance. The behaviour-physiology interactions of manneristic behaviour are not fully understood. Altered brain metabolism and disturbed perceptivity of social signals may be involved.

[Akathisia]

The syndrome of akathisia typically consists of a subjective component, e.g. inner restlessness and an urge to move, and observable symptoms such as restless legs and inability to sit still. In most cases akathisia is caused by neuroleptics. There are several subtypes of akathisia according to the time of onset in the course of neuroleptic treatment. In clinical routine extrapyramidal motor disturbances are often underestimated or misinterpreted. As far as akathisia is concerned, differential diagnosis of restlessness or of repetitive movement patterns may be problematic. Non-compliance and impulsive behaviour are regarded as possible complications of akathisia, but systematic investigations are lacking. The pathophysiology of akathisia is not clear, but it probably differs from other pharmacologically induced motor disturbances. If warrantable, the first step in akathisia treatment is dose-reduction of the causing agent. Anticholinergic drugs, benzodiazepines, and beta-receptor blockers may be effective. Clinical assessment and survey of the patient's behaviour, e.g. during occupational therapy and group therapy is important for an early diagnosis of akathisia so that complications may be minimised.

[Delusional "pseudotranssexualism" in schizophrenic psychosis]

The case of a 32-year old man suffering from a 10-year course of schizophrenia is presented. The man's delusions include the conviction of being of the opposite sex and thus, he applied for an operational correction of his gender according to the law of transsexualism. Based on the evident problems arising from this case, the differential diagnosis of genuine transsexualism is discussed.