Am
J Psychiatry
136:7,
TOPICAL
CSF BY
July
PAPERS:
Copper
STEPHEN
1979
Some
Clinical
Findings
in Schizophrenia P. TYRER,
M.B., H. TREVOR
DELVES,
PH.D.,
The authors measured copper levels in the cerebrospinalfluid of8 schizophrenic subjects and 6 controls. The schizophrenic subjects had significantly lower CSF copper values than the controls, tt’hich is consistent ia’ith the hypothesis that there is reduced central activity ofcopper-dependent enzymes in schizophrenia These enzymes , tyrosine hydroxylase and dopamine-f3-hydroxylase, are involved in the synthesis and catabolism of dopamine. .
ONE OF THE most favored theories on the etiology of schizophrenia is concerned with the role of dopamine. It is known that the majority ofdrugs effective in treating schizophrenia block the receptors at which dopamine acts (1). At least two enzymes involved in dopaminergic regulation are copper-dependent-dopaminc-f3-hydroxylase (DBH), which converts dopamine to norepinephrine, and tyrosine hydroxylase, which atalyzcs the hydroxylation of tyrosinc to produce
Presented at the 1st Meeting chopharmacology. Montreal, ceived Oct. 3, 1978; revised
of the Canadian College of NeuropsyQue. , Canada, April 27-28, 1978. ReFeb. 22, 1979; accepted March 16, 1979.
At the time this work was done Dr. Tyrer was Visiting Associate Professor, Department of Psychiatry, Queen’s University. Kingston, Ont., Canada. He is currently Visiting Assistant Professor, Millhauser Laboratories, Neuropsychopharmacology Unit, New York University Medical Center, 550 First Ave., New York, N.Y. 10016. Dr. Delves is Senior Lecturer, Institute of Child Health, University of London, England. where Dr. Weller is Lecturer in Psychiatry, Charing Cross Hospital. The authors wish to thank Mr. P. Minty of Charing Cross Hospital for help in the coding and transfer of the CSF specimens, Dr. J.S. Lawson of Queen’s University for help with statistical analysis, and Professor S.R. Hirsch for helping to facilitate the study.
The Editor
papers
in this
considers
in Schizophrenia
section this
are
material
grouped
around
to constitute
0002-953X179/08/0937/03/S00.40
a specific
MALCOLM
P.1. WELLER,
B.M.
dopa. Copper deficiency may be associated with reduced activity of these enzymes. A number of studies (2-4) have demonstrated raised serum copper in schizophrenia. However, such diverse conditions as myocardial infarction, infections, acute stress, and estrogen therapy also raise serum copper (5). To determine whether abnormality in copper metabolism is central in schizophrenia, Greiner and associates (6) looked at the copper content in the brains of individuals with this disease. In a postmortem study on 12 subjects, they showed that there was no difference in the amount ofcoppcr in the brains of schizophrenic, brain-damaged, and normal subjects. To our knowledge, there has been no published paper on CSF copper in schizophrenia. This work was designed to look at the differences between copper 1evels in the CSF of schizophrenic subjects and in that of nonschizophrenic controls.
METHOD
All patients exhibiting delusions or hallucinations in clear consciousness who entered the admission ward of a London teaching hospital were screened with the Present State Examination (PSE) (7) before receiving any treatment. The PSE is a structured clinical interview administered by personnel trained in its use that indicates the presence or absence of psychiatric symptoms according to clearly defined criteria. It has been used extensively in cross-cultural studies and has been found to be reliable even when administered by psychiatrists of widely different training (8). A computer program, known as CATEGO, classifies collected data according to 12 main diagnostic classes (7). Patients who had not received regular neuroleptic
topic.
a comnprehensive ©
AND
Publication analysis
American
here of the
Psychiatric
does
not,
however,
imply
that
the
topic. Association
937
CSF
COPPER
IN
Am
SCHIZOPHRENIA
J Psychiatry
136:7, July 1979
drugs in the month before interview were given the PSE. All those who fulfilled the nuclear syndrome category on the CATEGO (essentially those with firstrank Schneidcrian symptoms) were evaluated further. They were asked for permission to perform a lumbar puncture as part of a research project and 8 of the 14 subjects gave informed consent to this procedure. All were acute admissions, and the nature of their symptomatology enabled clear-cut diagnoses. In addition to core schizophrenic symptoms, patients S and 8 also had delusions of persecution. Patients 2 and 7 had received 100 mg of chlorpromazinc and 10 mg of haloperidol, respectively, 4 days before the lumbar puncture. However, these patients were included in the survey as they fulfilled all the other criteria. Some of the patients had received benzodiazepine drugs as hypnotics but had not taken any other drugs for at least S days before the lumbar puncture. Control CSF samples were obtained from patients undergoing myelography for suspected lumbar disc lesions. The case notes of these patients were investigated following this procedure and those patients who were taking drugs other than benzodiazcpines and nonopiate analgesics were excluded from the analysis. Two patients with possible psychiatric illness were
TABLE 1 CSF Copper
likewise
The results are consistent with the hypothesis that there is reduced central activity of copper-dependent enzymes in schizophrenia, although this is by no means the only explanation for the findings. The cop-
excluded.
No
female
subject
was
taking
an
oral contraceptive. Copper does not alter greatly after infancy (9) so the control and schizophrenic subjects were only roughly matched for age. Six of the 8 schizophrenic subjects were white, one came from the West Indies, and another was from the Middle East. One of the control subjects was from Pakistan. It has been reported that American blacks have higher serum coppers than whites (10). Immediately after collection, CSF specimens were stored at -20#{176}C. Four to nine months elapsed before the specimens were analyzed blind at a different hospital. Copper was measured directly in 50-pi volumes of CSF samples with a pulse-nebulizer technique similar to that described by Manning (1 1). This is an extension of conventional atomic absorption techniques. In all but two schizophrenic patients it was possible to obtam at least two CSF samples, and the results of the
analyses
in these
of copper
variance
RESU
cases
estimations
model
were was
(12) and
averaged. analyzed
was
acceptable
The by an
reliability analysis
of
at r=0.8l.
LTS
The schizophrenic subjects had significantly lower CSF copper values than the control subjects (table I). All the schizophrenic patients except 1 had CSF values less than I molIlitcr, whereas all the control subjects except 1 had CSF copper levels of more than 1 imoUliter. The 2 subjects with delusions of persecution did not show any difference from the other 5 subjects. 938
Concentration
in Schizophrenic
Patients
CSF Subject
and Controls Copper (j.tmol/liter)
Sex
Age
M F M F
23 26 27 30
1.55 0.50 0.85 0.77
5b
M
33
0.40
6
M F F
33 34 70
0.65 0.65 0.90
Schizophrenic I 2 3 4
patients
7b
8 Mean (± Controls I 2b
SD)
0.78±0.35 M M
22 23
3.30 1.45
3a
M
28
3.10
4
M F
29 39 40
a
6 Mean aSubject bNonwhite
p=.0i,
Level
M (±SD) had
taken
Mann-Whitney
benzodiazepines
within
I week
0.75 1.90 1.45 1.99± lOP before test.
U Test.
DISCUSSION
per-containing enzymes, tyrosine hydroxylase and DBH, arc involved in the synthesis and catabolism of dopamine. The central role of copper in their activity is supported by the finding of reduced catecholamine production in neonatal copper-deficient rats (13). Deficiency of DBH activity in the autopsied brains of schizophrenics was reported in 1973 by Wise and Stein (14), although this finding has not been confirmed (15, 16). Low
activity of DBH in the serum of schizophrenics was recently reported in Japan (17), although previous studies were contradictory (18, 19). In any case, the correlation between CSF DBH activity and its activity in serum is poor (20). There is a need to elucidate CSF DBH activity in schizophrenia and supplement a preliminary report (21). Although the samples were analyzed many months after they were collected, they were stored in the same refrigerator and at the same temperature. Over some months evaporation could occur, but this would lead to a rise in the copper levels of all the specimens. In fact, the mean CSF copper level in the schizophrenic subjects is lower than that reported in normal subjects (22, 23). Much lower figures were obtained by Kjellin (24) 15 years ago (0.25 molJlitcr). Our control values are higher than those reported by these authors, and the possibility exists that our control subjects were not representative of healthy volunteers. Further studies are needed to determine the consistency of these findings.
Am
J Psychiatry
136:7, July 1979
TYRER,
REFERENCES
12.
1. Carlsson A, Lindqvist M: Effect of chiorpromazine or haloperidol on formation of 3-methoxytyramine and normetanephrine in mouse brain. Acta Pharmacol Toxicol 20: 140-144, 1963 2. Heilmeyer L, Keiderling W, Struve C: Kupfer und eisen als korpereigene wirkstoffe und ihre bedeutung beim krankheitsgeschehen. Jena, Germany, Fischer, 1941 3. Alias AG, Vijayan N, Nair DS, et al: Serum ceruloplasmin in schizophrenia: significant increase in acute cases especially in catatonia. Biol Psychiatry 4:231-238, 1972 4. Olatunbosun DA, Akindele MO, Adadevoh BK, et al: Serum copper in schizophrenia in Nigerians. Br J Psychiatry 127:119121, 1975 5. Pfeiffer CC, Iliev V: A study of zinc deficiency and copper cx-
6.
7.
8.
cess in the schizophrenias. Int Rev Neurobiol, Supplement 1:141-165, 1972 Greiner AC, Chan SC, Nicolson GA: Human brain contents of calcium, copper, magnesium and zinc in some neurological pathologies. Clin Chim Acta 64:211-213, 1975 Wing JK, Copper JE, Sartonus N: The Measurement and Classification of Psychiatric bridge University Press, World Health Organization: phrenia. Geneva, WHO,
Symptoms,
11.
ed. London,
Cam-
1974 The
International
Study
of Schizo-
1973
9. Henkin RI, Schulman JD, Schulman CB,
10.
9th
et al: Changes in total non-diffusable and diffusable plasma zinc and copper during infancy. J Pediatr 82:831-837, 1972 Creason JP, Hammer DI, Colucci AV, et al: Blood trace metals in military recruits. South Med J 69:289-293, 1976 Manning DC: Aspirating small volume samples in flame atomic absorption spectroscopy. Atomic Absorption Newsletter 14:99102, 1975
13. 14. 15.
16.
17. 18.
19.
20.
Ebel RL: Estimation 16:407-424, 1951 Prohaska JR, Wells
of the WW:
reliability Copper
DELVES,
of ratings. deficiency
AND
WELLER
Psychometrika in the
developing
rat brain. J Neurochem 23:91-98, 1974 Wise CD, Stein L: Dopamine-/3-hydroxylase deficits in the brains of schizophrenic patients. Science 181 :344-347, 1973 Wyatt Ri, Schwartz MA, Erdely E, et al: Dopamine beta hydroxylase activity in brains of chronic schizophrenic patients. Science 187:368-370, 1975 Farley IJ, Price KS, McCullough E, et al: Norepinephrine in chronic paranoid schizophrenia: above-normal levels in limbic forebrain. Science 200:456-457, 1978 Fujita K, Ito T, Maruta K, et al: Serum dopamine-f3-hydroxylase in schizophrenic patients. J Neurochem 30:1569-1572, 1978 Shopsin B, Freedman LS, Goldstein M, et al: Serum dopamine hydroxylase activity and affective states. Psychopharmacologia 27:11-16, 1972 Meltzer HY, Cho HW, Carroll BJ, et al: Serum dopamine-betahydroxylase activity in the affective disorders, and schizophrenia. Arch Gen Psychiatry 33:585-591, 1976 Fujita K, Maruta K, Teradaira R, et al: Dopamine-/3-hydroxylase activity in human CSF and serum. J Neurochem 29:11411142, 1977
21. Okada
1, Ohta 1, Shinoda T, et al: Dopamine-beta-hydroxylase
activity in serum and CSF in neuropsychiatric diseases. Neuropsychobiology 2:139-144, 1976 22. Meret 5, Henkin RI: Simultaneous direct estimation by atomic absorption spectrophotometry of copper and zinc in serum, urine and cerebro-spinal fluid. Clin Chem 17:369-373, 1971 23. Documenta Geigy Scientific Tables. Basel, Switzerland, JR Geigy, 1970 24. Kjellin K: Determination of copper in CSF by activation analysis. J Neurochem 10:89-93, 1963
939
J Psychiatry
136:7,
TOPICAL
CSF BY
July
PAPERS:
Copper
STEPHEN
1979
Some
Clinical
Findings
in Schizophrenia P. TYRER,
M.B., H. TREVOR
DELVES,
PH.D.,
The authors measured copper levels in the cerebrospinalfluid of8 schizophrenic subjects and 6 controls. The schizophrenic subjects had significantly lower CSF copper values than the controls, tt’hich is consistent ia’ith the hypothesis that there is reduced central activity ofcopper-dependent enzymes in schizophrenia These enzymes , tyrosine hydroxylase and dopamine-f3-hydroxylase, are involved in the synthesis and catabolism of dopamine. .
ONE OF THE most favored theories on the etiology of schizophrenia is concerned with the role of dopamine. It is known that the majority ofdrugs effective in treating schizophrenia block the receptors at which dopamine acts (1). At least two enzymes involved in dopaminergic regulation are copper-dependent-dopaminc-f3-hydroxylase (DBH), which converts dopamine to norepinephrine, and tyrosine hydroxylase, which atalyzcs the hydroxylation of tyrosinc to produce
Presented at the 1st Meeting chopharmacology. Montreal, ceived Oct. 3, 1978; revised
of the Canadian College of NeuropsyQue. , Canada, April 27-28, 1978. ReFeb. 22, 1979; accepted March 16, 1979.
At the time this work was done Dr. Tyrer was Visiting Associate Professor, Department of Psychiatry, Queen’s University. Kingston, Ont., Canada. He is currently Visiting Assistant Professor, Millhauser Laboratories, Neuropsychopharmacology Unit, New York University Medical Center, 550 First Ave., New York, N.Y. 10016. Dr. Delves is Senior Lecturer, Institute of Child Health, University of London, England. where Dr. Weller is Lecturer in Psychiatry, Charing Cross Hospital. The authors wish to thank Mr. P. Minty of Charing Cross Hospital for help in the coding and transfer of the CSF specimens, Dr. J.S. Lawson of Queen’s University for help with statistical analysis, and Professor S.R. Hirsch for helping to facilitate the study.
The Editor
papers
in this
considers
in Schizophrenia
section this
are
material
grouped
around
to constitute
0002-953X179/08/0937/03/S00.40
a specific
MALCOLM
P.1. WELLER,
B.M.
dopa. Copper deficiency may be associated with reduced activity of these enzymes. A number of studies (2-4) have demonstrated raised serum copper in schizophrenia. However, such diverse conditions as myocardial infarction, infections, acute stress, and estrogen therapy also raise serum copper (5). To determine whether abnormality in copper metabolism is central in schizophrenia, Greiner and associates (6) looked at the copper content in the brains of individuals with this disease. In a postmortem study on 12 subjects, they showed that there was no difference in the amount ofcoppcr in the brains of schizophrenic, brain-damaged, and normal subjects. To our knowledge, there has been no published paper on CSF copper in schizophrenia. This work was designed to look at the differences between copper 1evels in the CSF of schizophrenic subjects and in that of nonschizophrenic controls.
METHOD
All patients exhibiting delusions or hallucinations in clear consciousness who entered the admission ward of a London teaching hospital were screened with the Present State Examination (PSE) (7) before receiving any treatment. The PSE is a structured clinical interview administered by personnel trained in its use that indicates the presence or absence of psychiatric symptoms according to clearly defined criteria. It has been used extensively in cross-cultural studies and has been found to be reliable even when administered by psychiatrists of widely different training (8). A computer program, known as CATEGO, classifies collected data according to 12 main diagnostic classes (7). Patients who had not received regular neuroleptic
topic.
a comnprehensive ©
AND
Publication analysis
American
here of the
Psychiatric
does
not,
however,
imply
that
the
topic. Association
937
CSF
COPPER
IN
Am
SCHIZOPHRENIA
J Psychiatry
136:7, July 1979
drugs in the month before interview were given the PSE. All those who fulfilled the nuclear syndrome category on the CATEGO (essentially those with firstrank Schneidcrian symptoms) were evaluated further. They were asked for permission to perform a lumbar puncture as part of a research project and 8 of the 14 subjects gave informed consent to this procedure. All were acute admissions, and the nature of their symptomatology enabled clear-cut diagnoses. In addition to core schizophrenic symptoms, patients S and 8 also had delusions of persecution. Patients 2 and 7 had received 100 mg of chlorpromazinc and 10 mg of haloperidol, respectively, 4 days before the lumbar puncture. However, these patients were included in the survey as they fulfilled all the other criteria. Some of the patients had received benzodiazepine drugs as hypnotics but had not taken any other drugs for at least S days before the lumbar puncture. Control CSF samples were obtained from patients undergoing myelography for suspected lumbar disc lesions. The case notes of these patients were investigated following this procedure and those patients who were taking drugs other than benzodiazcpines and nonopiate analgesics were excluded from the analysis. Two patients with possible psychiatric illness were
TABLE 1 CSF Copper
likewise
The results are consistent with the hypothesis that there is reduced central activity of copper-dependent enzymes in schizophrenia, although this is by no means the only explanation for the findings. The cop-
excluded.
No
female
subject
was
taking
an
oral contraceptive. Copper does not alter greatly after infancy (9) so the control and schizophrenic subjects were only roughly matched for age. Six of the 8 schizophrenic subjects were white, one came from the West Indies, and another was from the Middle East. One of the control subjects was from Pakistan. It has been reported that American blacks have higher serum coppers than whites (10). Immediately after collection, CSF specimens were stored at -20#{176}C. Four to nine months elapsed before the specimens were analyzed blind at a different hospital. Copper was measured directly in 50-pi volumes of CSF samples with a pulse-nebulizer technique similar to that described by Manning (1 1). This is an extension of conventional atomic absorption techniques. In all but two schizophrenic patients it was possible to obtam at least two CSF samples, and the results of the
analyses
in these
of copper
variance
RESU
cases
estimations
model
were was
(12) and
averaged. analyzed
was
acceptable
The by an
reliability analysis
of
at r=0.8l.
LTS
The schizophrenic subjects had significantly lower CSF copper values than the control subjects (table I). All the schizophrenic patients except 1 had CSF values less than I molIlitcr, whereas all the control subjects except 1 had CSF copper levels of more than 1 imoUliter. The 2 subjects with delusions of persecution did not show any difference from the other 5 subjects. 938
Concentration
in Schizophrenic
Patients
CSF Subject
and Controls Copper (j.tmol/liter)
Sex
Age
M F M F
23 26 27 30
1.55 0.50 0.85 0.77
5b
M
33
0.40
6
M F F
33 34 70
0.65 0.65 0.90
Schizophrenic I 2 3 4
patients
7b
8 Mean (± Controls I 2b
SD)
0.78±0.35 M M
22 23
3.30 1.45
3a
M
28
3.10
4
M F
29 39 40
a
6 Mean aSubject bNonwhite
p=.0i,
Level
M (±SD) had
taken
Mann-Whitney
benzodiazepines
within
I week
0.75 1.90 1.45 1.99± lOP before test.
U Test.
DISCUSSION
per-containing enzymes, tyrosine hydroxylase and DBH, arc involved in the synthesis and catabolism of dopamine. The central role of copper in their activity is supported by the finding of reduced catecholamine production in neonatal copper-deficient rats (13). Deficiency of DBH activity in the autopsied brains of schizophrenics was reported in 1973 by Wise and Stein (14), although this finding has not been confirmed (15, 16). Low
activity of DBH in the serum of schizophrenics was recently reported in Japan (17), although previous studies were contradictory (18, 19). In any case, the correlation between CSF DBH activity and its activity in serum is poor (20). There is a need to elucidate CSF DBH activity in schizophrenia and supplement a preliminary report (21). Although the samples were analyzed many months after they were collected, they were stored in the same refrigerator and at the same temperature. Over some months evaporation could occur, but this would lead to a rise in the copper levels of all the specimens. In fact, the mean CSF copper level in the schizophrenic subjects is lower than that reported in normal subjects (22, 23). Much lower figures were obtained by Kjellin (24) 15 years ago (0.25 molJlitcr). Our control values are higher than those reported by these authors, and the possibility exists that our control subjects were not representative of healthy volunteers. Further studies are needed to determine the consistency of these findings.
Am
J Psychiatry
136:7, July 1979
TYRER,
REFERENCES
12.
1. Carlsson A, Lindqvist M: Effect of chiorpromazine or haloperidol on formation of 3-methoxytyramine and normetanephrine in mouse brain. Acta Pharmacol Toxicol 20: 140-144, 1963 2. Heilmeyer L, Keiderling W, Struve C: Kupfer und eisen als korpereigene wirkstoffe und ihre bedeutung beim krankheitsgeschehen. Jena, Germany, Fischer, 1941 3. Alias AG, Vijayan N, Nair DS, et al: Serum ceruloplasmin in schizophrenia: significant increase in acute cases especially in catatonia. Biol Psychiatry 4:231-238, 1972 4. Olatunbosun DA, Akindele MO, Adadevoh BK, et al: Serum copper in schizophrenia in Nigerians. Br J Psychiatry 127:119121, 1975 5. Pfeiffer CC, Iliev V: A study of zinc deficiency and copper cx-
6.
7.
8.
cess in the schizophrenias. Int Rev Neurobiol, Supplement 1:141-165, 1972 Greiner AC, Chan SC, Nicolson GA: Human brain contents of calcium, copper, magnesium and zinc in some neurological pathologies. Clin Chim Acta 64:211-213, 1975 Wing JK, Copper JE, Sartonus N: The Measurement and Classification of Psychiatric bridge University Press, World Health Organization: phrenia. Geneva, WHO,
Symptoms,
11.
ed. London,
Cam-
1974 The
International
Study
of Schizo-
1973
9. Henkin RI, Schulman JD, Schulman CB,
10.
9th
et al: Changes in total non-diffusable and diffusable plasma zinc and copper during infancy. J Pediatr 82:831-837, 1972 Creason JP, Hammer DI, Colucci AV, et al: Blood trace metals in military recruits. South Med J 69:289-293, 1976 Manning DC: Aspirating small volume samples in flame atomic absorption spectroscopy. Atomic Absorption Newsletter 14:99102, 1975
13. 14. 15.
16.
17. 18.
19.
20.
Ebel RL: Estimation 16:407-424, 1951 Prohaska JR, Wells
of the WW:
reliability Copper
DELVES,
of ratings. deficiency
AND
WELLER
Psychometrika in the
developing
rat brain. J Neurochem 23:91-98, 1974 Wise CD, Stein L: Dopamine-/3-hydroxylase deficits in the brains of schizophrenic patients. Science 181 :344-347, 1973 Wyatt Ri, Schwartz MA, Erdely E, et al: Dopamine beta hydroxylase activity in brains of chronic schizophrenic patients. Science 187:368-370, 1975 Farley IJ, Price KS, McCullough E, et al: Norepinephrine in chronic paranoid schizophrenia: above-normal levels in limbic forebrain. Science 200:456-457, 1978 Fujita K, Ito T, Maruta K, et al: Serum dopamine-f3-hydroxylase in schizophrenic patients. J Neurochem 30:1569-1572, 1978 Shopsin B, Freedman LS, Goldstein M, et al: Serum dopamine hydroxylase activity and affective states. Psychopharmacologia 27:11-16, 1972 Meltzer HY, Cho HW, Carroll BJ, et al: Serum dopamine-betahydroxylase activity in the affective disorders, and schizophrenia. Arch Gen Psychiatry 33:585-591, 1976 Fujita K, Maruta K, Teradaira R, et al: Dopamine-/3-hydroxylase activity in human CSF and serum. J Neurochem 29:11411142, 1977
21. Okada
1, Ohta 1, Shinoda T, et al: Dopamine-beta-hydroxylase
activity in serum and CSF in neuropsychiatric diseases. Neuropsychobiology 2:139-144, 1976 22. Meret 5, Henkin RI: Simultaneous direct estimation by atomic absorption spectrophotometry of copper and zinc in serum, urine and cerebro-spinal fluid. Clin Chem 17:369-373, 1971 23. Documenta Geigy Scientific Tables. Basel, Switzerland, JR Geigy, 1970 24. Kjellin K: Determination of copper in CSF by activation analysis. J Neurochem 10:89-93, 1963
939
