Schkophrenia Research, 8 (1992)75-80 c; 1992 Elsevier Science Publishers B.V. All rights
SCHIZO
75 reserved
0920-9964/92/$05.00
00254
Left-handed first-episode, neuroleptic-naive schizophrenic patients have a higher prevalence of autoantibodies K.N.
Roy
Chengappa”,‘,
Rohan
Ganguli”,b~c, Zan W. Yanga*c, J.S. Bra?, and B.S. Rabin”*b.c
Lailai
Li”
“Depurtmmr qf Psychiutry ilmmunopsychiatry Program), Western Psychiatric Inslitule and Clinic, University of Pittsburgh. School qf Medicine, bDeparimenr of Pathology (Division ~f‘lmmunoparhology), University of Pittsburgh, School qf Medicine. and ‘Brain. Behaviour and Immunity, Cenier. University of Pittsburgh und Carnegie-Mellon University, Pittsburgh. PA, USA (Received
29 January
1992. revision
received
12 May
1992, accepted
19 May 1992)
Using standard immunological techniques, sera from first-episode, neuroleptic-naive schizophrenic patients (n = 5 1) and age, race and sex matched healthy controls (n = 5 1) were screened for seven common autoantibodies. Significantly more left-handed (67%) than right-handed (23%) schizophrenic patients had autoantibodies (p= 0.011). Left-handed schizophrenic patients were six times more likely than right-handed patients or controls and four times more likely than left-handed controls to test positive for autoantibodies (p= 0.012). These data suggest that disease and sinistrality contribute to the excess of autoantibodies in schizophrenia. Kq
words: Autoantibodies;
Handedness;
Neuroleptic-Naive:
INTRODUCTION
There is an intriguing association between lefthandedness and immune dysfunction (Geschwind and Behan, 1982). Since this earlier report, several though not all, studies have reported an excess of autoimmune disorders among left-handed subjects (Pennington et al., 1987; Smith, 1987). In animals, brain lesions in specific right and left cerebral regions regulate immune functions in a differential manner (Biziere et al., 1985; Neveu, 1992) suggesting that there is lateralization of neural control over immune functions. These findings may be relevant to schizophrenia as there have been reports of both the occurrence of immune abnormalities (Delisi and Wyatt, 1982; DeLisi et al., 1985; Ganguli et al., 1987) and an excess of lefthandedness among schizophrenic patients (Gur, Correspondencr to: R. Ganguli, lmmunopsychiatry Program, Schizophrenia Module. Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh. PA 15213-2593, USA.
First-Episode;
(Schizophrenia)
1977; Nasrallah et al., 1982). Disease, psychotropic medications and familial factors have all been implicated in the induction of autoantibodies among schizophrenic patients (Delisi and Wyatt, 1982; Chengappa et al., 199la; Berglund et al., 1970; Gottfries and Gottfries, 1974; Johnstone and Whaley, 1975; Zarrabi et al., 1979; Canoso et al., 1990; Yannitisi et al., 1990; Chengappa et al., 1992; Sirota et al., 1991). We have previously reported that female gender, African-American ethnicity and left-handedness are associated with autoantibodies in normal healthy individuals (Chengappa et al., 199lb). As part of our ongoing investigations of autoimmunity in schizophrenia, we have gathered data on autoantibodies as diagnostic markers of autoimmune disorders (Carpenter and Rabin, 1983), as well as, data on handedness as an indicator of motor cerebral dominance. Thus, we investigated the prevalence of autoantibodies among neuroleptic-naive, first-episode schizophrenic patients and healthy control subjects who were matched to patients for age, ethnicity,
gender and handedness. As alluded to earlier, the selection of these two groups of subjects allowed us to control for some of the factors known to be associated with the induction of autoantibodies.
received neuroleptic drugs prior to the blood draw, which was obtained within 1 to 5 days after admission to hospital. Some of these patients had recieved a few doses of lorazepam for agitation or chloral hydrate for insomnia.
METHODS
Handedness Handedness was determined using a questionaire that included questions on the hand used for writing, foot used to kick a ball and the eye used to look out of a monocular paper tube (Chengappa et al, 1991b). Subjects were classified as dextral (right-handed) if all items were done with the right and the rest were classed as non-dextrals (left- or mixed-handed).
Subjects Subjects were selected from among patients and controls who had provided informed consent and were participants in an ongoing study of immunologic dysfunction in schizophrenia. The patients (n= 51) were selected from 61 consecutive admissions to the Schizophrenia Module of the Western Psychiatric Institute and Clinic, Pittsburgh, PA. Patients were examined during their first episode of psychosis by a research psychiatrist and an experienced psychiatric nurse using a modified SADS interview (Spitzer and Endicott, 1978), and included if they met the RDC Criteria for Schizophrenia or SchizoAffective Disorder, mainly schizophrenic (Spitzer et al., 1978). All of the 61 patients were followed up for at least 6 months or longer (in some cases, the follow-up has extended to 4 years), and two independent research psychiatrists confirmed the diagnosis of schizophrenia using the DSM-IIIR criteria (APA, 1987); thus 10 patients who did not meet the DSM-IIIR criteria were excluded from the study. Control subjects were recruited from the Greater Pittsburgh metropolitan area and interviewed by either a research psychiatrist or experienced nurse. Healthy controls (n= 51) were selected from a pool of 270 controls, matched to patients for age, race, gender and handedness. Patients or controls using immunoactive drugs or those with a history of recent viral illness (4 weeks) and those with a history of active medical illnesses were excluded; as were controls with a history of current or past psychiatric illness. Furthermore, controls with a history of multiple allergies to various environmental allergens and drugs were excluded as well. Where necessary, in addition to review of the medical records, corroborative history was obtained from a physician or family member. Subjects with a history of substance abuse (past 3 months) were excluded from the study. Sera was obtained from subjects in the morning after an overnight fast. None of the patients had
Autoantibodies Sera were screened for 7 autoantibodies using three different laboratory procedures: thyroglobulin and thyroid microsomal antigen were detected by indirect haemagglutination (Miles Inc, IN). Indirect immunoflorescence was used to detect nuclear antigen, smooth muscle, mitochondria or parietal cells (using HEp-2 cell lines and mouse stomach/ kidney slides purchased from Kallestad Labs, MN.) Rheumatoid factor was determined by fluorescence immunoassay (FIAX, MA Whitaker Bioproducts, MD). In this university-hospital clinical laboratory, positive titers have been established as follows: 1 : 100 for thyroglobulin, 1 : 400 for thyroid microsomes, 1 : 40 for antinuclear, smooth muscle, mitochondrial and parietal cell antibodies and > 25 IU/ml for rheumatoid factor. The inter-assay variability for all these assays using controls provided in the kits is under 15%. The results were read by an immunologist who had no knowledge of the handedness data. Subjects were classed as autoantibody positive if they had titers equal to or above the clinical threshold for any one or more of the autoantibodies mentioned above, and the rest were classed as autoantibody negative. Statistical analyses Patients and controls were sorted on the basis of handedness and within and between group comparisons were conducted. Where appropriate, the Yates’ corrected chi-square test or the Fisher exact test (2-tailed) were used to test differences. Also calculated were the odds and odds ratios of autoan-
tibody positivity among patients and controls classed on handedness, and the generalized Mantel-Haenszel chi-square statistic was used to test significance across all strata in a multi-way contingency table.
f
AUTOANTIBODIESAMONG RIGHT AND LEFT-HANDED NEUROLEPTIC-NAIVESCHIZOPHRENICPATIENTS ,~~, ;iG;HY CONTROL SUBJECTS 77
3 3
RESULTS
The demographic and handedness characteristics of both groups are shown in Table 1. Significantly more left-handed (67%) than right-handed (23%) individuals had autoantibodies schizophrenic (Fisher’s exact p=O.Ol I; see Table 2 and Fig. 1). Even though left-handed controls (33%) had more CONTROL SUBJECTS
TABLE I Demographic and handedness characieristics of neuroleptic-naive schizophrenic paiients and matched control subjects Age (years) Mean *SD Race White Black Sex Male Female Handedness Right Left
TABLE
SCHIZOPHRENIC PATIENTS
Fig. 1. Autoantibodies among right and left-handed leptic-naive, first-episode schizophrenic patients and control subjects.
24.56 + 7.64
neurohealthy
autoantibodies than right-handed controls (23%) this did not reach statistical significance [Table 2). As a group, left-handed schizophrenic patients (67%) were six times more likely than right-handed patients (23%) or right-handed controls (23%) and four times more likely than left-handed controls (33%) to test positive for autoantibodies (Mantel-Haenszel x2=6.33, df= I, p=O.O12); Table 2 and Fig. 1). Partly due to the small num-
33 18 31 20 39 12
2
Auroantibody stams among neuroleptic-naive schizophrenic patients and matched controls: Sorted on handedness Group/Handedness
Odds qfAA+/AA-
Controls Left (n= 12) Right (n = 39)
0.50 (4/8)
Patients Left (n= 12) Right (n = 39)
2 @/4)
Odds ratio
Mantel-Haenszel x2 test across ail levels
I .67
x2 = 6.33
0.30 (9/30)
p=o.o12 6.67
0.30 (9/30)
AA + , Autoantibody positive; AA -, Autoantibody negative (see text for details). Figures in parenthesis indicate AA + /AA “Left-handed patients (67%) had significantly more autoantibodies than right-handed schizophrenic patients (23%). Fisher’s exact 2-tailed p = 0.0 I 1.
78
bers of subjects, statistically non-significant results emerged when left-handed patients (67% were autoantibody positive) were compared to lefthanded controls (33%). There were no differences in the percentages of right-handed patients (23%) or right-handed controls (23%) testing positive for autoantibodies.
DISCUSSION
In spite of controlling for factors known to be associated with autoantibodies (psychotropic medications, female gender, African-American ethnicity and left-handedness), these data suggest that left-handed first-episode, neuroleptic-naive schizophrenic individuals have significantly more autoantibodies than the other groups under study. Older subjects (Schuller et al., 1981; Yannitsi et al., 1990) are more likely to test positive for autoantibodies. However, as our subjects were young adults, age cannot explain the higher prevalence of autoantibodies among the left-handed patients. These data confirm previous reports that neuroleptic-naive schizophrenic individuals have a higher prevalence of certain autoantibodies (Delisi and Wyatt, 1982; Chengappa et al., 199 la). These findings also suggest that in some schizophrenic individuals, disease rather than medications contribute to the induction of autoantibodies. There are several mechanisms by which immune dysregulation can induce autoantibodies; and while this study was not designed to look at these mechanisms specifically, some points merit emphasis. Firstly, there is evidence that not only schizophrenic individuals but their healthy relatives have circulating autoantibodies (Sirota et al, 1991). This supports the role of familial and genetic factors in autoantibody induction in some patients with schizophrenia. The initial enthusiasm linking neuroleptic drugs and the HLA system (Smeraldi and Scorza-Smeraldi, 1976) was dampened when another group was unable to replicate the association between chlorpromazine and anti-HLA-A I antibodies (Alexander et al., 1990). However, in a separate line of enquiry, Canoso et al. (1982) reported the presence of autoantibodies among patients receiving chronic chlorpromazine treatment and the presence of the HLA-B44 antigen.
In this particular study, the presence of HLA-B44 was associated with neurological complications that included tardive dyskinesia. The exact mechanisms by which the HLA system and schizophrenic disorder or neuroleptic drugs interact to induce autoantibodies is not presently known. It is also possible that schizophrenia induces alterations in nucleoproteins rendering them antigenic, and thus initiate an autoimmune response. Evidence for this finding has come from histochemical studies of Stefanis and Issidorides (1976) who reported that neutrophils of drug-free schizophrenic patients revealed an abnormal distribution of histones which then returned to normal on neuroleptic treatment. Although, it is unclear how this change in nucleohistones might induce autoantibodies, we have shown that a subgroup of medicated schizophrenic patients have a higher prevalence of antihistone antibodies as compared to neurolepticnaive. first-episode patients or healthy controls. Finally, the relationship between left-handedness which is a marker of altered cerebral asymmetry (Wittelson, 1980) and autoantibodies needs to be explained. There is growing body of evidence that supports the relationship between left-handedness and immune dysfunction. Geschwind and Galaburda (1987) proposed that an adverse intrauterine hormonal environment (high levels of testosterone or progesterone) could affect the slower developing left-hemisphere thereby weakening its control and result in right hemisphere dominance and left-handedness. As an extension of this hypothesis, they predicted that prenatal hormones could also affect other susceptible organ systems like the thymus gland and cause immune dysfunction. Since, their original observation that lefthanders have an excess of certain autoimmune disorders (Geschwind and Behan. 1982). other investigators have confirmed this to be true for some. though not all autoimmune disorders (Pennington et al., 1987; Smith, 1987). In an earlier study, we found that healthy left-handed subjects had a higher prevalence of circulating autoantibodies than right-handed individuals (Chengappa et al., 1991b). In support of human studies, brain lesions at specific sites in animals suggest that the left and right cerebral regions modulate immune functions in a differential manner (Biziere et al., 1985; Neveu, 1992). In a recent review, McManus and Bryden (199 1) critically reassessed the Gesch-
79
wind-Galaburda-Behan theory of cerebral lateralization and suggested ways to test the various predictions using a causal model. Future studies that address these questions using the suggestions in the McManus and Bryden (1991) paper may elucidate the nature and direction of neuralimmune interactions in schizophrenia and other disorders. Birth complications has featured prominently as one of the environmental factors associated with left-handedness. In a recent review, Searleman et al. (1989) concluded that the majority of studies support the association between birth complications and left-handedness. This finding is interesting to schizophrenia, as several, though not all, investigators have separately reported an excess of left-handedness and obstetric complications among schizophrenic patients as compared to control subjects (Gur, 1977; Nasrallah et al., 1982; McNeil and Kaij, 1978; Parnas et al,, 1982; Lewis and Murray, 1987). Whether obstetric complications are associated with an increased prevalence of lefthandedness, as well as an increased prevalence of autoantibodies needs to be examined in a separate study. The autoimmune hypothesis of schizophrenia posits that a subgroup of schizophrenic patients has an excess of autoimmune disorders, circulating autoantibodies, and lowered interleukin-2 production (Ganguli et al., 1987, 1989; Villemain et al., 1989). In addition to these biological markers of autoimmunity, if replicated in a larger sample, left-handedness may be of relevance as a clinical marker of a predisposition to autoimmunity among schizophrenic individuals.
ACKNOWLEDGEMENTS
The authors acknowledge Rosemarie Perla, M. S. for project coordination; Wendy Solomon, M. P. M., Marcia Deleo, R. N., Colin Bachert for data collection and management and Richard Ulrich, M. S. for statistical advice. Dr. Robert Kelly, Ph.D. supervised the serological testing in the laboratory. K.N.R.C. was supported in part by an NIMH Training Grant (MH 16804-10). R.G. is supported in part by an NIMH Research Scientist Development Award (MH 00710) and by a
NARSAD Established Investigator Award. The work is also supported in part by an NTMH grant (MH 41883) to R.G. and B.S.R.
REFERENCES
Alexander. R.C., Coggiano, M.A. and Wyatt, R.J. (1990) Failure to find interference between Anti-HLA antibodies and chlorpromazine. Biol. Psychiatry 27. 6422648. American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders, 3rd Ed, revised. APA Press, Washington, DC. Berglund. S., Gottfries, C.G., Gottfries, I., Stormby, K. (1970) Chlorpromazine-induced antinuclear factors. Acta Med Stand 187, 67-74. Biziere K., Guillaumin J.M., Degenne. D., Bardos. P.. Renoux, M. and Renoux, G. (1985) Lateralized neocortical modulation of the T-Cell lineage. In: Neural modulation of immunity. R. Guillemin, M. Cohn, and T. Melnechuk, (Eds). Raven Press. New York, pp. 81-94. Canoso, R.T.. de Oliveira, R.M. and Nixon. R.A. (1990) Neuroleptic-associated antibodies: A prevalence study. Biol. Psychiatry 27, 8633870. Canoso. R., Lewis. M.E. and Yunis. E.J. (1982) Association of HLA-B44 with chlorpromazine-induced autoantibodies. Clin. Imm. Immunopath. 25, 2788282. Carpenter. A.B. and Rabin, B.S. (1983) Autoimmunity in immunopathology. Clinics Lab. Med. 3. 745-762. Chengappa, K.N.R.. Cochrdn, J., Rabin, B. and Ganguli, R. (199lb) Handedness and Autoantibodies. Lancet 338, 694. Chengappa, K.N.R.. Carpenter, A.B., Yang. Z.W., Brar, J.B., Rabin, B.S. and Ganguli, R. (1992) Elevated IgG Anti-Histone Antibodies in a Subgroup of Medicated Schizophrenic Patients. Schizophr. Res. 7, 49-54. Chengappa. K.N.R., Carpenter, A.B., Keshavan. M.S., Yang, Z.W., Kelly, R., Rabin. B.S. and Ganguli. R. (1991a) Elevated IgG and IgM Anti-Cardiolipin Antibodies in a Subgroup of Medicated and Unmedicated Schizophrenic Patients. Biol. Psychiatry 30, 731-735. DeLisi, L.E., Weber, R.J. and Pert, C.B. (1985) Are them antibodies against the brain in the sera from schizophrenic patients? Review and Prospectus. Biol. Psychiatry 20, 110-115. DeLisi, L.E. and Wyatt, R.J. (1982) Abnormal immune regulation in schizophrenic patients. Psychopharmacol. Bull, 18, 158-163. Ganguli, R., Rabin. B.S. and Belle, S.H. (1989) Decreased interleukin-2 production in schizophrenic patients. Biol. Psychiatry 26, 4277430. Ganguli, R., Rabin, B.S., Kelly, R.H., Lyte, M. and Ragu, U. (1987) Clinical and laboratory evidence of autoimmunity in acute schizophrenia. Ann. N.Y. Acad. Sci. 496, 676-685. Geschwind. N. and Behan. P. (I 982) Left-handedness: association with immune disease, migraine and developmental learning disorder. Proc. Nat. Acad. Sci. USA 79, 509775100. Geschwind, N. and Galaburda, A.M. (1987) Cerebral lateraliza-
80
tion: Biological mechanisms, associations. and pathology. MIT Press, Cambridge, MA. Gottfries, C.G. and Gottfries, 1. (1974) Antinuclear factors in relation to age, sex, mental disease and treatment with phenothiazines. Acta Psychiatr. Stand. 255, 193-201, Gur, R.E. (1977) Motoric laterality imbalance in schizophrenia. Arch. Gen. Psychiatry 34, 33-37. Johnstone, E.C. and Whaley, K. (1975) Antinuclear antibodies in psychiatric illness: Their relationship to diagnosis and drug treatment. Br. Med. J. 2, 7244725. Lewis, SW. and Murray, R.M. (1987) Obstetric complications, neurodevelopmental deviance and risk of schizophrenia. J. Psychiatric Res. 21, 413-422. McManus, I.C. and Bryden, M.P. (1991) Geschwind’s theory of cerebral lateralization: Developing a formal, causal model. Psychol. Bull. I IO, 2377253. McNeil, T.F. and Kaij, L. (1978) Obstetric factors in the development of schizophrenia: Complications in the births of preschizophrenics and in reproduction by schizophrenic parents. In: C. Wynne, R.L. Cromwell, S. Mathysse (eds). High risk and premorbid development. Wiley, New York. pp. 401-429. Nasrahah, H.A.. McCalley, M.W. and Kuperman, S. (1982) Neurological differences between paranoid and nonparanoid schizophrenia: 1. Sensory-motor lateralization. J. Clin. Psychiatry 43. 3055306. Neveu, P.J. (1992) Minireview-Asymmetrical Brain Modulation of Immune Reactivity in Mice: A model for studying interindividual differences and physiological population heterogeneity ? Life Sci. 50, 1-6. Parnas. J., Schulsinger, F., Teasdale, T.W., Schulsinger, H., Feldman, P.M. and Mednick, S.A. (1982) Perinatal complications and clinical outcome within schizophrenia spectrum. Br. J. Psychiatry 144. 416-420. Pennington, B.F., Smith, S.D., Kimberling, W.J., Green, P.A. and Haith, M.M. (1987) Left-handedness and immune disorders in familial dyslexics. Arch. Neural. 44, 434-439. Schuller, E., Allinquant, B., Reboul, J., Fournier, C., Dardenne, M. and Bach, J.F. (1981) Immunological studies in human ageing II. Associated increase in Anti-RNA and Anti-DNA antibodies. J. Clin. Lab. Immunol. 6. 107-l IO.
Searleman, A., Porac, C. and Coren, S. (1989) The relationship between birth order, birth stress and lateral preferences: A critical review. Psychol. Bull. 105, 3977408. Sirota, P., Schild, K., Firer, M., Tanay, A., Elizur, A., Meytes, D. and Slor, H. (1991) Autoantibodies to DNA in multicase families with schizophrenia. Biol. Psychiatry (Suppl.) 29, 103A. Smeraldi, E. and Scorza-Smeraldi, R. (1976) Interference between anti-HLA antibodies and chlorpromazine. Nature 260, 5322533. Smith, J. (1987) Left-handedness: Its association with allergic disease. Neuropsychologia 25, 6655674. Spitzer, R.L. and Endicott, J. (1978) Schedule for affective disorders and schizophrenia. New York State Psychiatric Institute, New York. Spitzer, R.L., Endicott, J. and Robbins. E. (1978) Research diagnostic criteria: rationale and reliability. Arch. Gen. Psychiatry 35, 773-775. Stefanis, C.N. and Issidorides, M.R. (1976) Histochemical changes in the blood cells of schizophrenic patients under pimozide. Biol. Psychiatry 1 I, 53-68. Villemain, F., Chatenoud, L., Galinowski, A., Homo-Delarche. F., Ginestet, D., Loo, H., Zarifian, E. and Bach, J.F. (1989) Aberrant T cell-mediated immunity in untreated schizophrenic patients: Deficient Interleukin-2 production. Am. J. Psychiatry 146, 6099616. Witelson. S.F. (1980) Neuroanatomical Asymmetry in LeftHanders: A review and implications for functional Asymmetry. In: J. Herron, (Ed.) Neuropsychology of left-handedness. Academic Press, New York. pp. 799113. Yannitsi, S.G., Manoussakis, M.N., Mavridis, A.K., Tzioufas. A.G., Loukas, S.B., Plataris, G.K., Liakos. A.D. and Moutsopoulos, H.M. (1990) Factors related to the presence of autoantibodies in patients with chronic mental disorders. Biol. Psychiatry 27, 7477756. Zarrabi, M.H., Zucker. S., Miller, F., Derman, R.M., Romano. G.S., Hartnett, J.A. and Varma, A.O. (1979) Immunologic and coagulation disorders in chlorpromazine treated patients. Ann. Intern. Med. 91, 194-199.
SCHIZO
75 reserved
0920-9964/92/$05.00
00254
Left-handed first-episode, neuroleptic-naive schizophrenic patients have a higher prevalence of autoantibodies K.N.
Roy
Chengappa”,‘,
Rohan
Ganguli”,b~c, Zan W. Yanga*c, J.S. Bra?, and B.S. Rabin”*b.c
Lailai
Li”
“Depurtmmr qf Psychiutry ilmmunopsychiatry Program), Western Psychiatric Inslitule and Clinic, University of Pittsburgh. School qf Medicine, bDeparimenr of Pathology (Division ~f‘lmmunoparhology), University of Pittsburgh, School qf Medicine. and ‘Brain. Behaviour and Immunity, Cenier. University of Pittsburgh und Carnegie-Mellon University, Pittsburgh. PA, USA (Received
29 January
1992. revision
received
12 May
1992, accepted
19 May 1992)
Using standard immunological techniques, sera from first-episode, neuroleptic-naive schizophrenic patients (n = 5 1) and age, race and sex matched healthy controls (n = 5 1) were screened for seven common autoantibodies. Significantly more left-handed (67%) than right-handed (23%) schizophrenic patients had autoantibodies (p= 0.011). Left-handed schizophrenic patients were six times more likely than right-handed patients or controls and four times more likely than left-handed controls to test positive for autoantibodies (p= 0.012). These data suggest that disease and sinistrality contribute to the excess of autoantibodies in schizophrenia. Kq
words: Autoantibodies;
Handedness;
Neuroleptic-Naive:
INTRODUCTION
There is an intriguing association between lefthandedness and immune dysfunction (Geschwind and Behan, 1982). Since this earlier report, several though not all, studies have reported an excess of autoimmune disorders among left-handed subjects (Pennington et al., 1987; Smith, 1987). In animals, brain lesions in specific right and left cerebral regions regulate immune functions in a differential manner (Biziere et al., 1985; Neveu, 1992) suggesting that there is lateralization of neural control over immune functions. These findings may be relevant to schizophrenia as there have been reports of both the occurrence of immune abnormalities (Delisi and Wyatt, 1982; DeLisi et al., 1985; Ganguli et al., 1987) and an excess of lefthandedness among schizophrenic patients (Gur, Correspondencr to: R. Ganguli, lmmunopsychiatry Program, Schizophrenia Module. Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh. PA 15213-2593, USA.
First-Episode;
(Schizophrenia)
1977; Nasrallah et al., 1982). Disease, psychotropic medications and familial factors have all been implicated in the induction of autoantibodies among schizophrenic patients (Delisi and Wyatt, 1982; Chengappa et al., 199la; Berglund et al., 1970; Gottfries and Gottfries, 1974; Johnstone and Whaley, 1975; Zarrabi et al., 1979; Canoso et al., 1990; Yannitisi et al., 1990; Chengappa et al., 1992; Sirota et al., 1991). We have previously reported that female gender, African-American ethnicity and left-handedness are associated with autoantibodies in normal healthy individuals (Chengappa et al., 199lb). As part of our ongoing investigations of autoimmunity in schizophrenia, we have gathered data on autoantibodies as diagnostic markers of autoimmune disorders (Carpenter and Rabin, 1983), as well as, data on handedness as an indicator of motor cerebral dominance. Thus, we investigated the prevalence of autoantibodies among neuroleptic-naive, first-episode schizophrenic patients and healthy control subjects who were matched to patients for age, ethnicity,
gender and handedness. As alluded to earlier, the selection of these two groups of subjects allowed us to control for some of the factors known to be associated with the induction of autoantibodies.
received neuroleptic drugs prior to the blood draw, which was obtained within 1 to 5 days after admission to hospital. Some of these patients had recieved a few doses of lorazepam for agitation or chloral hydrate for insomnia.
METHODS
Handedness Handedness was determined using a questionaire that included questions on the hand used for writing, foot used to kick a ball and the eye used to look out of a monocular paper tube (Chengappa et al, 1991b). Subjects were classified as dextral (right-handed) if all items were done with the right and the rest were classed as non-dextrals (left- or mixed-handed).
Subjects Subjects were selected from among patients and controls who had provided informed consent and were participants in an ongoing study of immunologic dysfunction in schizophrenia. The patients (n= 51) were selected from 61 consecutive admissions to the Schizophrenia Module of the Western Psychiatric Institute and Clinic, Pittsburgh, PA. Patients were examined during their first episode of psychosis by a research psychiatrist and an experienced psychiatric nurse using a modified SADS interview (Spitzer and Endicott, 1978), and included if they met the RDC Criteria for Schizophrenia or SchizoAffective Disorder, mainly schizophrenic (Spitzer et al., 1978). All of the 61 patients were followed up for at least 6 months or longer (in some cases, the follow-up has extended to 4 years), and two independent research psychiatrists confirmed the diagnosis of schizophrenia using the DSM-IIIR criteria (APA, 1987); thus 10 patients who did not meet the DSM-IIIR criteria were excluded from the study. Control subjects were recruited from the Greater Pittsburgh metropolitan area and interviewed by either a research psychiatrist or experienced nurse. Healthy controls (n= 51) were selected from a pool of 270 controls, matched to patients for age, race, gender and handedness. Patients or controls using immunoactive drugs or those with a history of recent viral illness (4 weeks) and those with a history of active medical illnesses were excluded; as were controls with a history of current or past psychiatric illness. Furthermore, controls with a history of multiple allergies to various environmental allergens and drugs were excluded as well. Where necessary, in addition to review of the medical records, corroborative history was obtained from a physician or family member. Subjects with a history of substance abuse (past 3 months) were excluded from the study. Sera was obtained from subjects in the morning after an overnight fast. None of the patients had
Autoantibodies Sera were screened for 7 autoantibodies using three different laboratory procedures: thyroglobulin and thyroid microsomal antigen were detected by indirect haemagglutination (Miles Inc, IN). Indirect immunoflorescence was used to detect nuclear antigen, smooth muscle, mitochondria or parietal cells (using HEp-2 cell lines and mouse stomach/ kidney slides purchased from Kallestad Labs, MN.) Rheumatoid factor was determined by fluorescence immunoassay (FIAX, MA Whitaker Bioproducts, MD). In this university-hospital clinical laboratory, positive titers have been established as follows: 1 : 100 for thyroglobulin, 1 : 400 for thyroid microsomes, 1 : 40 for antinuclear, smooth muscle, mitochondrial and parietal cell antibodies and > 25 IU/ml for rheumatoid factor. The inter-assay variability for all these assays using controls provided in the kits is under 15%. The results were read by an immunologist who had no knowledge of the handedness data. Subjects were classed as autoantibody positive if they had titers equal to or above the clinical threshold for any one or more of the autoantibodies mentioned above, and the rest were classed as autoantibody negative. Statistical analyses Patients and controls were sorted on the basis of handedness and within and between group comparisons were conducted. Where appropriate, the Yates’ corrected chi-square test or the Fisher exact test (2-tailed) were used to test differences. Also calculated were the odds and odds ratios of autoan-
tibody positivity among patients and controls classed on handedness, and the generalized Mantel-Haenszel chi-square statistic was used to test significance across all strata in a multi-way contingency table.
f
AUTOANTIBODIESAMONG RIGHT AND LEFT-HANDED NEUROLEPTIC-NAIVESCHIZOPHRENICPATIENTS ,~~, ;iG;HY CONTROL SUBJECTS 77
3 3
RESULTS
The demographic and handedness characteristics of both groups are shown in Table 1. Significantly more left-handed (67%) than right-handed (23%) individuals had autoantibodies schizophrenic (Fisher’s exact p=O.Ol I; see Table 2 and Fig. 1). Even though left-handed controls (33%) had more CONTROL SUBJECTS
TABLE I Demographic and handedness characieristics of neuroleptic-naive schizophrenic paiients and matched control subjects Age (years) Mean *SD Race White Black Sex Male Female Handedness Right Left
TABLE
SCHIZOPHRENIC PATIENTS
Fig. 1. Autoantibodies among right and left-handed leptic-naive, first-episode schizophrenic patients and control subjects.
24.56 + 7.64
neurohealthy
autoantibodies than right-handed controls (23%) this did not reach statistical significance [Table 2). As a group, left-handed schizophrenic patients (67%) were six times more likely than right-handed patients (23%) or right-handed controls (23%) and four times more likely than left-handed controls (33%) to test positive for autoantibodies (Mantel-Haenszel x2=6.33, df= I, p=O.O12); Table 2 and Fig. 1). Partly due to the small num-
33 18 31 20 39 12
2
Auroantibody stams among neuroleptic-naive schizophrenic patients and matched controls: Sorted on handedness Group/Handedness
Odds qfAA+/AA-
Controls Left (n= 12) Right (n = 39)
0.50 (4/8)
Patients Left (n= 12) Right (n = 39)
2 @/4)
Odds ratio
Mantel-Haenszel x2 test across ail levels
I .67
x2 = 6.33
0.30 (9/30)
p=o.o12 6.67
0.30 (9/30)
AA + , Autoantibody positive; AA -, Autoantibody negative (see text for details). Figures in parenthesis indicate AA + /AA “Left-handed patients (67%) had significantly more autoantibodies than right-handed schizophrenic patients (23%). Fisher’s exact 2-tailed p = 0.0 I 1.
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bers of subjects, statistically non-significant results emerged when left-handed patients (67% were autoantibody positive) were compared to lefthanded controls (33%). There were no differences in the percentages of right-handed patients (23%) or right-handed controls (23%) testing positive for autoantibodies.
DISCUSSION
In spite of controlling for factors known to be associated with autoantibodies (psychotropic medications, female gender, African-American ethnicity and left-handedness), these data suggest that left-handed first-episode, neuroleptic-naive schizophrenic individuals have significantly more autoantibodies than the other groups under study. Older subjects (Schuller et al., 1981; Yannitsi et al., 1990) are more likely to test positive for autoantibodies. However, as our subjects were young adults, age cannot explain the higher prevalence of autoantibodies among the left-handed patients. These data confirm previous reports that neuroleptic-naive schizophrenic individuals have a higher prevalence of certain autoantibodies (Delisi and Wyatt, 1982; Chengappa et al., 199 la). These findings also suggest that in some schizophrenic individuals, disease rather than medications contribute to the induction of autoantibodies. There are several mechanisms by which immune dysregulation can induce autoantibodies; and while this study was not designed to look at these mechanisms specifically, some points merit emphasis. Firstly, there is evidence that not only schizophrenic individuals but their healthy relatives have circulating autoantibodies (Sirota et al, 1991). This supports the role of familial and genetic factors in autoantibody induction in some patients with schizophrenia. The initial enthusiasm linking neuroleptic drugs and the HLA system (Smeraldi and Scorza-Smeraldi, 1976) was dampened when another group was unable to replicate the association between chlorpromazine and anti-HLA-A I antibodies (Alexander et al., 1990). However, in a separate line of enquiry, Canoso et al. (1982) reported the presence of autoantibodies among patients receiving chronic chlorpromazine treatment and the presence of the HLA-B44 antigen.
In this particular study, the presence of HLA-B44 was associated with neurological complications that included tardive dyskinesia. The exact mechanisms by which the HLA system and schizophrenic disorder or neuroleptic drugs interact to induce autoantibodies is not presently known. It is also possible that schizophrenia induces alterations in nucleoproteins rendering them antigenic, and thus initiate an autoimmune response. Evidence for this finding has come from histochemical studies of Stefanis and Issidorides (1976) who reported that neutrophils of drug-free schizophrenic patients revealed an abnormal distribution of histones which then returned to normal on neuroleptic treatment. Although, it is unclear how this change in nucleohistones might induce autoantibodies, we have shown that a subgroup of medicated schizophrenic patients have a higher prevalence of antihistone antibodies as compared to neurolepticnaive. first-episode patients or healthy controls. Finally, the relationship between left-handedness which is a marker of altered cerebral asymmetry (Wittelson, 1980) and autoantibodies needs to be explained. There is growing body of evidence that supports the relationship between left-handedness and immune dysfunction. Geschwind and Galaburda (1987) proposed that an adverse intrauterine hormonal environment (high levels of testosterone or progesterone) could affect the slower developing left-hemisphere thereby weakening its control and result in right hemisphere dominance and left-handedness. As an extension of this hypothesis, they predicted that prenatal hormones could also affect other susceptible organ systems like the thymus gland and cause immune dysfunction. Since, their original observation that lefthanders have an excess of certain autoimmune disorders (Geschwind and Behan. 1982). other investigators have confirmed this to be true for some. though not all autoimmune disorders (Pennington et al., 1987; Smith, 1987). In an earlier study, we found that healthy left-handed subjects had a higher prevalence of circulating autoantibodies than right-handed individuals (Chengappa et al., 1991b). In support of human studies, brain lesions at specific sites in animals suggest that the left and right cerebral regions modulate immune functions in a differential manner (Biziere et al., 1985; Neveu, 1992). In a recent review, McManus and Bryden (199 1) critically reassessed the Gesch-
79
wind-Galaburda-Behan theory of cerebral lateralization and suggested ways to test the various predictions using a causal model. Future studies that address these questions using the suggestions in the McManus and Bryden (1991) paper may elucidate the nature and direction of neuralimmune interactions in schizophrenia and other disorders. Birth complications has featured prominently as one of the environmental factors associated with left-handedness. In a recent review, Searleman et al. (1989) concluded that the majority of studies support the association between birth complications and left-handedness. This finding is interesting to schizophrenia, as several, though not all, investigators have separately reported an excess of left-handedness and obstetric complications among schizophrenic patients as compared to control subjects (Gur, 1977; Nasrallah et al., 1982; McNeil and Kaij, 1978; Parnas et al,, 1982; Lewis and Murray, 1987). Whether obstetric complications are associated with an increased prevalence of lefthandedness, as well as an increased prevalence of autoantibodies needs to be examined in a separate study. The autoimmune hypothesis of schizophrenia posits that a subgroup of schizophrenic patients has an excess of autoimmune disorders, circulating autoantibodies, and lowered interleukin-2 production (Ganguli et al., 1987, 1989; Villemain et al., 1989). In addition to these biological markers of autoimmunity, if replicated in a larger sample, left-handedness may be of relevance as a clinical marker of a predisposition to autoimmunity among schizophrenic individuals.
ACKNOWLEDGEMENTS
The authors acknowledge Rosemarie Perla, M. S. for project coordination; Wendy Solomon, M. P. M., Marcia Deleo, R. N., Colin Bachert for data collection and management and Richard Ulrich, M. S. for statistical advice. Dr. Robert Kelly, Ph.D. supervised the serological testing in the laboratory. K.N.R.C. was supported in part by an NIMH Training Grant (MH 16804-10). R.G. is supported in part by an NIMH Research Scientist Development Award (MH 00710) and by a
NARSAD Established Investigator Award. The work is also supported in part by an NTMH grant (MH 41883) to R.G. and B.S.R.
REFERENCES
Alexander. R.C., Coggiano, M.A. and Wyatt, R.J. (1990) Failure to find interference between Anti-HLA antibodies and chlorpromazine. Biol. Psychiatry 27. 6422648. American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders, 3rd Ed, revised. APA Press, Washington, DC. Berglund. S., Gottfries, C.G., Gottfries, I., Stormby, K. (1970) Chlorpromazine-induced antinuclear factors. Acta Med Stand 187, 67-74. Biziere K., Guillaumin J.M., Degenne. D., Bardos. P.. Renoux, M. and Renoux, G. (1985) Lateralized neocortical modulation of the T-Cell lineage. In: Neural modulation of immunity. R. Guillemin, M. Cohn, and T. Melnechuk, (Eds). Raven Press. New York, pp. 81-94. Canoso, R.T.. de Oliveira, R.M. and Nixon. R.A. (1990) Neuroleptic-associated antibodies: A prevalence study. Biol. Psychiatry 27, 8633870. Canoso. R., Lewis. M.E. and Yunis. E.J. (1982) Association of HLA-B44 with chlorpromazine-induced autoantibodies. Clin. Imm. Immunopath. 25, 2788282. Carpenter. A.B. and Rabin, B.S. (1983) Autoimmunity in immunopathology. Clinics Lab. Med. 3. 745-762. Chengappa, K.N.R.. Cochrdn, J., Rabin, B. and Ganguli, R. (199lb) Handedness and Autoantibodies. Lancet 338, 694. Chengappa, K.N.R.. Carpenter, A.B., Yang. Z.W., Brar, J.B., Rabin, B.S. and Ganguli, R. (1992) Elevated IgG Anti-Histone Antibodies in a Subgroup of Medicated Schizophrenic Patients. Schizophr. Res. 7, 49-54. Chengappa. K.N.R., Carpenter, A.B., Keshavan. M.S., Yang, Z.W., Kelly, R., Rabin. B.S. and Ganguli. R. (1991a) Elevated IgG and IgM Anti-Cardiolipin Antibodies in a Subgroup of Medicated and Unmedicated Schizophrenic Patients. Biol. Psychiatry 30, 731-735. DeLisi, L.E., Weber, R.J. and Pert, C.B. (1985) Are them antibodies against the brain in the sera from schizophrenic patients? Review and Prospectus. Biol. Psychiatry 20, 110-115. DeLisi, L.E. and Wyatt, R.J. (1982) Abnormal immune regulation in schizophrenic patients. Psychopharmacol. Bull, 18, 158-163. Ganguli, R., Rabin. B.S. and Belle, S.H. (1989) Decreased interleukin-2 production in schizophrenic patients. Biol. Psychiatry 26, 4277430. Ganguli, R., Rabin, B.S., Kelly, R.H., Lyte, M. and Ragu, U. (1987) Clinical and laboratory evidence of autoimmunity in acute schizophrenia. Ann. N.Y. Acad. Sci. 496, 676-685. Geschwind. N. and Behan. P. (I 982) Left-handedness: association with immune disease, migraine and developmental learning disorder. Proc. Nat. Acad. Sci. USA 79, 509775100. Geschwind, N. and Galaburda, A.M. (1987) Cerebral lateraliza-
80
tion: Biological mechanisms, associations. and pathology. MIT Press, Cambridge, MA. Gottfries, C.G. and Gottfries, 1. (1974) Antinuclear factors in relation to age, sex, mental disease and treatment with phenothiazines. Acta Psychiatr. Stand. 255, 193-201, Gur, R.E. (1977) Motoric laterality imbalance in schizophrenia. Arch. Gen. Psychiatry 34, 33-37. Johnstone, E.C. and Whaley, K. (1975) Antinuclear antibodies in psychiatric illness: Their relationship to diagnosis and drug treatment. Br. Med. J. 2, 7244725. Lewis, SW. and Murray, R.M. (1987) Obstetric complications, neurodevelopmental deviance and risk of schizophrenia. J. Psychiatric Res. 21, 413-422. McManus, I.C. and Bryden, M.P. (1991) Geschwind’s theory of cerebral lateralization: Developing a formal, causal model. Psychol. Bull. I IO, 2377253. McNeil, T.F. and Kaij, L. (1978) Obstetric factors in the development of schizophrenia: Complications in the births of preschizophrenics and in reproduction by schizophrenic parents. In: C. Wynne, R.L. Cromwell, S. Mathysse (eds). High risk and premorbid development. Wiley, New York. pp. 401-429. Nasrahah, H.A.. McCalley, M.W. and Kuperman, S. (1982) Neurological differences between paranoid and nonparanoid schizophrenia: 1. Sensory-motor lateralization. J. Clin. Psychiatry 43. 3055306. Neveu, P.J. (1992) Minireview-Asymmetrical Brain Modulation of Immune Reactivity in Mice: A model for studying interindividual differences and physiological population heterogeneity ? Life Sci. 50, 1-6. Parnas. J., Schulsinger, F., Teasdale, T.W., Schulsinger, H., Feldman, P.M. and Mednick, S.A. (1982) Perinatal complications and clinical outcome within schizophrenia spectrum. Br. J. Psychiatry 144. 416-420. Pennington, B.F., Smith, S.D., Kimberling, W.J., Green, P.A. and Haith, M.M. (1987) Left-handedness and immune disorders in familial dyslexics. Arch. Neural. 44, 434-439. Schuller, E., Allinquant, B., Reboul, J., Fournier, C., Dardenne, M. and Bach, J.F. (1981) Immunological studies in human ageing II. Associated increase in Anti-RNA and Anti-DNA antibodies. J. Clin. Lab. Immunol. 6. 107-l IO.
Searleman, A., Porac, C. and Coren, S. (1989) The relationship between birth order, birth stress and lateral preferences: A critical review. Psychol. Bull. 105, 3977408. Sirota, P., Schild, K., Firer, M., Tanay, A., Elizur, A., Meytes, D. and Slor, H. (1991) Autoantibodies to DNA in multicase families with schizophrenia. Biol. Psychiatry (Suppl.) 29, 103A. Smeraldi, E. and Scorza-Smeraldi, R. (1976) Interference between anti-HLA antibodies and chlorpromazine. Nature 260, 5322533. Smith, J. (1987) Left-handedness: Its association with allergic disease. Neuropsychologia 25, 6655674. Spitzer, R.L. and Endicott, J. (1978) Schedule for affective disorders and schizophrenia. New York State Psychiatric Institute, New York. Spitzer, R.L., Endicott, J. and Robbins. E. (1978) Research diagnostic criteria: rationale and reliability. Arch. Gen. Psychiatry 35, 773-775. Stefanis, C.N. and Issidorides, M.R. (1976) Histochemical changes in the blood cells of schizophrenic patients under pimozide. Biol. Psychiatry 1 I, 53-68. Villemain, F., Chatenoud, L., Galinowski, A., Homo-Delarche. F., Ginestet, D., Loo, H., Zarifian, E. and Bach, J.F. (1989) Aberrant T cell-mediated immunity in untreated schizophrenic patients: Deficient Interleukin-2 production. Am. J. Psychiatry 146, 6099616. Witelson. S.F. (1980) Neuroanatomical Asymmetry in LeftHanders: A review and implications for functional Asymmetry. In: J. Herron, (Ed.) Neuropsychology of left-handedness. Academic Press, New York. pp. 799113. Yannitsi, S.G., Manoussakis, M.N., Mavridis, A.K., Tzioufas. A.G., Loukas, S.B., Plataris, G.K., Liakos. A.D. and Moutsopoulos, H.M. (1990) Factors related to the presence of autoantibodies in patients with chronic mental disorders. Biol. Psychiatry 27, 7477756. Zarrabi, M.H., Zucker. S., Miller, F., Derman, R.M., Romano. G.S., Hartnett, J.A. and Varma, A.O. (1979) Immunologic and coagulation disorders in chlorpromazine treated patients. Ann. Intern. Med. 91, 194-199.
