217
Psychiatry Research, 44~217-225 Elsevier
Melatonin and Cortisol Secretion in Patients With Primary 0 bsessive-Compulsive Disorder Francesco Catapano, and Dargut Kemali
Palmiero
Monteleone.
Antonio
Fuschino.
Mario Mai.
Received May 12, 1992; revised version received September 3, 1992; accepted September 19, 1992. Abstract. Plasma levels of melatonin and cortisol were measured over a 24-hour period in seven patients with primary obsessive-compulsive disorder (OCD) and seven matched healthy control subjects. In OCD patients, the 24-hour secretion of melatonin was reduced as compared with that in healthy control subjects, whereas its circadian rhythm was preserved. In addition, in OCD patients, the overall secretion of cortisol was higher than that in control subjects, but there was no change in the circadian pattern of cortisol secretion. No correlation was found between clinical parameters and hormone levels. Key Words.
Norepinephrine,
pineal
gland,
compulsions,
circadian
rhythm,
cortisol. Although the prevailing biological model of obsessive-compulsive disorder (OCD) centers on the role of serotonin (Zohar et al., 1987), several lines of evidence support the hypothesis that an abnormal noradrenergic function may be involved as well. Animal data have implicated increased norepinephrine (NE) transmission in the mediation of experimentally induced behaviors that resemble compulsions (Kokkinidis and Anisman, 1976). Clinical data have suggested that clonidine, an qadrenergic receptor agonist, has marked, even if transitory, antiobsessional effects in subjects with primary OCD (Knesevich, 1982; Hollander et al., 1988a, 19886, 1991), although it cannot be excluded that these effects are related to clonidine’s sedative effects. Finally, blunted growth hormone responses to clonidine, as well as increased levels of plasma free 3-methoxy&hydroxyphenylglycol (MHPG) and NE, have been reported in OCD patients (Siever et al., 1983; Insel et al., 1984; Rasmussen et al., 1987). These data provide support for the hypothesis that OCD is associated with both increased presynaptic noradrenergic activity and decreased postsynaptic adrenergic receptor responsiveness. However, other studies (Lee et al., 1990; Benkelfat et al., 1991; Hollander et al., 1991) have not confirmed noradrenergic dysfunction in patients with OCD. One approach to the investigation of noradrenergic transmission involves the
Francesco Catapano, M.D., is Research
Staff Psychiatrist; Palm&o Monteleone, M.D., is Temporary Research Staff Psychiatrist; Antonio Fuschino is Research Fellow; Mario Maj, M.D., is Professor of Mental Hygiene; and Dargut Kemali, M.D., is Professor of Psychiatry and Chairman, Institute of Psychiatry, First Medical School, University of Naples, Naples, Italy. (Reprint requests to Dr. P. Monteleone, Institute of Psychiatry, First Medical School, University of Naples, Largo Madonna delle Grazie, 80138 Naples, Italy.) 01651781/92/$05.00
@ 1992 Elsevier Scientific
Publishers
Ireland
Ltd.
218 assessment of the circadian rhythm of melatonin, the main secretory product of the pineal gland. Indeed, in both animal and human studies, melatonin has been shown to be secreted primarily at night under the direct influence of noradrenergic fibers that arise from the superior cervical ganglia (Arendt et al., 1987; Reiter et al., 1991). Hence, abnormalities of melatonin secretion might be related to a noradrenergic dysfunction. In the present study, we explored the circadian rhythm of melatonin in a group of drug-free primary OCD patients and in a group of matched healthy control subjects. Furthermore, since an inverse correlation between plasma cortisol and melatonin concentrations has been reported in some depressed patients (Wetterberg, 1983; Claustrat et al., 1984) we also measured plasma cortisol levels.
Methods who met DSM-III-R criteria for OCD (American Psychiatric Association, 1987), with no previous history of other psychiatric disorders, agreed to participate in the study. The OCD group consisted of four men and three women who ranged in age from 22 to Seven patients
60 years (mean 34.8, SD = 14.4). Two women were normally menstruating and were tested in the follicular phase of their menstrual cycle (days 5-9 after menses); the third female subject was postmenopausal. All patients had been drug free for at least 3 weeks. Table 1 presents the patients’ clinical characteristics, including age, sex, height, weight, and total duration of illness. At the time of the study, clinical psychopathological assessments were carried out by two psychiatrists who used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1986). The YBOCS was constructed to assess time, interference, distress, resistance, and control of obsessions and compulsions. Ratings from 0 (none) to 4 (extreme, incapacitating) are combined to arrive at total obsession and compulsion scores of O-20 each. There is also a Y-BOCS total score, which is the sum of the obsession and compulsion subscale scores and can range from 0 to 40. Moreover, although no subject met DSWIZZ-R criteria for mood disorders or had a positive family history of affective disorders, the presence of concomitant depressive symptoms was evaluated by the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960). Ratings on the Y-BOCS and the HRSD were made on the day of blood sampling. The normal control group consisted of seven healthy subjects who were individually matched to the seven patients on the following variables: age, sex, body weight, and height (Table 1). The two normally menstruating female control subjects were both tested in the follicular phase of their menstrual cycle (days 6-9 after menses). Where possible, the patient and his or her matched control subject were tested at intervals no longer than 3 weeks. This was achieved in all but one pair (#3), in which the interval was 5 weeks. Both patients and healthy volunteers received a physical examination and had routine laboratory tests to exclude metabolic alterations and any other organic disease. None of them had a family history of diabetes mellitus. They were asked to abstain from drinking alcoholic or caffeine-containing drinks for 24 hours before and during the period of the experimental sessions. Subjects were admitted to our Clinical Investigation Unit at 1700h. A standard meal was served at 1900h. At 1930h, a butterfly needle was inserted into an antecubital vein and kept patent with saline solution, which was slowly infused. At 2000h, the first blood sample was collected; thereafter subjects rested supine in dim room light (about 300 lux). At 2100h, lights were turned off, and all procedures were carried out with the aid of a red light. This light is neither bright enough nor of the proper wavelength to influence melatonin secretion (Reiter, 1985). Further blood specimens were drawn at 2200h, 2400h, OlOOh, 0200h, 03OOh, 0400h, 0600h, 0800h, 1200h, and 1600h. Subjects were allowed to sleep between 2200h and 0700h, when lights were turned on. A note was made at each sampling time as to whether subjects were asleep or awake.
F
50
50
0
N
M
M
F
F
M
M
M
25
25
27
26
26
29
22
22
0
N
0
N
0
N
0
N
N
14.4
34.8
14.2
34.8
F
32
N
0
F
35
0
M
M
60
N
M
59
0
F
Sex
Age (yr)
9.8
166.5
5.9
165.7
165
172
185
175
168
161
166
160
154
167
170
160
158
165
Height (cm)
9.5
72.0
5.4
71.0
75
68
90
80
66
4.1
8.5
9
6 -
4 -
74
62
5.7
3.2
13.0
3.5
14.2
11
11 22 27.2
13 -
17 -
30 -
18 -
3.9
10.0
7 -
17 -
13 -
9 -
7 11 -
19 -
16
9 -
6 -
11 -
HRSD total score
11
17
16 11 -
Y-BOCS compulsions score
Y-BOCS obsessions score
11
30 -
34 -
7 -
22 -
1 -
65
33 -
5 -
20 -
Y-BOCS total score
14 -
64
71
72
74
75
65
Weight (kg)
Duration of illness (yr)
Nofee.N = normal control. 0 = patient with obsessive-compulsive disorder. Y-BOCS = Yale-Brown Obsessive-Compulsive Scale. HRSD = Hamilton Rating Scale for Depression.
SD
Mean
SD
Mean
7
6
5
4
3
2
1
Pair
Table
220 Blood was collected in tubes with lithium heparin as anticoagulant. Plasma was separated by centrifugation at 3000 rpm and stored at -20 “C until assayed for melatonin and cortisol. Melatonin and cortisol assays for each patient and his or her matched control subject were run in the same lot. After extraction by diethylether, melatonin concentrations were determined by a radioimmunoassay (RIA) that used a sheep melatonin antiserum from Guildhay Antisera (University of Surrey, UK), 3H-melatonin tracer (specific activity: 85 kCi/mole; Amersham, Bucks, UK) and unlabeled melatonin (Sigma Chemical Co., St. Louis, MO, USA). Free and antibody-bound fractions of 3H-melatonin were separated using a dextran-coated charcoal solution (29&0.2%). The lower detection limit of the assay was 5 pg/ml; the upper limit was 250 pg/ml. Intra-assay and interassay coefficients of variation (CVs) were 5.1% and 9.8%, respectively. Plasma cortisol levels were determined by double-antibody RIA with commercial kits purchased from Ares-Serono (Milan, Italy). The lower detection limit of the assay was 27 nmole/ 1; the upper limit was 2700 nmole/ 1. Intra-assay and interassay CVs were 5% and 8%, respectively. Differences in hormonal secretion between OCD patients and healthy subjects were tested for statistical significance using a repeated measures two-way analysis of variance (ANOVA) with the Greenhouse-Geisser adjusted degrees of freedom and Student’s t test for paired data. Moreover, where the ANOVA indicated a significant difference between the two subject groups, the integrated areas under the curve (AUCs) were calculated and compared by Student’s t test for paired data. Relationships between AUC melatonin or AUC cortisol and psychopathological measures were evaluated by Pearson’s product-moment correlation test.
Results Table 1 shows the matching of pairs of subjects on pertinent variables. As expected, no statistically significant difference was observed between the patient group and the control group in mean age, height, or weight. The circadian rhythm of melatonin was preserved in OCD patients, but plasma levels of the indoleamine were lower than they were in healthy subjects (Fig. 1). A two-way ANOVA with repeated measures showed significant main effects for group (F=5.111;df=l, 12;p=0.04)andtime(F=23.158;df= 10, 12O;p=O.O0001), with no significant interaction effect (F= 1.340; df = 10, 120, NS), indicating that the time pattern of melatonin secretion was similar in the two groups, whereas the overall production of melatonin was significantly different. Accordingly, the melatonin AUC in healthy subjects was significantly higher than the AUC in OCD patients @ = 0.003, Student’s t test for paired data). Fig. 1 presents statistically significant differences between the two groups at the various time points. Plasma cortisol levels in OCD patients were higher than in normal control subjects (Fig. 2). A two-way ANOVA with repeated measures showed significant main effects for group (F= 8.348; df = 1, 12; p = 0.01) and time (F= 18.018; df = 10, 120; p = O.OOOl), and no significant interaction effect between time and group (F = 0.966; df = 10, 120; NS), indicating that the timing of cortisol secretion was similar between OCD patients and healthy control subjects, whereas the total secretion of the glucocorticoid was different. Indeed, the cortisol AUC in OCD patients was significantly higher than in healthy subjects (p = 0.04) (Fig. 2). Plasma cortisol levels at 20OOh,2200h, OlOOh,03OOh, and 0800h were significantly higher in OCD patients than in normal subjects (Fig. 2).
221 Fig. 1. Melatonin circadian rhythm in patients with obsessive-compulsive disorder (closed circles) and in healthy volunteers (open circles)
The dark bar indicates the dark period. Data are expressed as mean f SEM. a = p < 0.01; b = p < 0.04; c = p < 0.03; d = p < 0.003 (Student’s t test for paired data).
A negative correlation was found between the AUC of melatonin and the AUC of cortisol in both healthy subjects (r = -0.44) and OCD patients (r = -0.42), but it did not reach statistical significance. No significant correlation was found between the AUC of melatonin or cortisol and Y-BOCS total, Y-BOCS obsession, Y-BOCS compulsion, or HRSD total scores. Fig. 2. Cortisol circadian rhythm in patients with obsessive-compulsive disorder (closed circles) and in healthy volunteers (open circles)
¶0¶6¶4lSS4
6 CLOCK
6
16
I6
HOURS
The dark bar indicates the dark period. Data are expressed as mean & SEM. a = p < 0.01; b = p < 0.05; c = p < 0.02; d = p < 0.03; e = p < 0.04 (SbJdent’s t test for paired data).
222
Discussion The main finding in this study is that in OCD patients, as compared to matched healthy control subjects, the melatonin and the cortisol circadian patterns are preserved, although, respectively, at a lower and higher level. To our knowledge, this is the first study exploring melatonin and cortisol rhythms in patients with primary OCD. Because it was necessary to have a staff member enter the experimental room at each time sampling, the subject’s sleep was sometimes interrupted. However, it seems unlikely that the interruptions in sleep affected melatonin production in our subjects, since the melatonin circadian rhythm is entrained to the light-dark cycle and not to sleep (Jimerson et al., 1977). The impairment of melatonin secretion in OCD patients appears to consist essentially in a blunting of the normal rise associated with the dark condition, and may reflect a reduction in the sensitivity of pineal adrenergic receptors. Indeed, the secretion of melatonin by the pineal gland is regulated mainly by pi- and, to a lesser degree, by cx,-adrenergic receptors located on the pinealocyte membranes (Reiter, 1991). Therefore, it is possible that an increased noradrenergic tone in OCD subjects could have induced a downward regulation of postsynaptic noradrenergic receptors, leading to a reduction in melatonin output from the pineal gland. Consistent with this hypothesis, increased plasma levels of NE and MHPG have been reported in drug-free OCD patients (Siever et al., 1983; Insel et al., 1984; Rasmussen et al., 1987). Moreover, although not confirmed by all authors (Hollander et al., 1991), a decreased postsynaptic adrenergic receptor responsiveness in OCD patients has been supported by a blunted growth hormone response to clonidine (Siever et al., 1983) and an increased cortisol response to yohimbine (Rasmussen et al., 1987). Alternatively, the reduced melatonin output from the pineal gland in our patients might be an expression of a specific defect of the noradrenergic transmission in the sympathetic pathway innervating the pineal gland. However, at present, no data are available to support this hypothesis. The lowered secretion of melatonin can also be regarded as an effect of a disturbance in the brain serotonergic system, which has been repeatedly postulated in OCD (for review, see Murphy et al., 1989). In fact, the pinealocytes synthesize melatonin from pineal serotonin, which in turn is derived from systemic tryptophan (Reiter, 1991). Hence, a reduction in the availability of plasma tryptophan, alterations in the metabolic pathway leading to the synthesis of pineal serotonin, or both could result in a deficiency of melatonin production in OCD patients. Our finding of an increased secretion of cortisol in OCD patients is in line with previous reports of a failure to suppress cortisol secretion in response to the dexamethasone suppression test (DST) in some OCD patients (Asberg et al., 1982; Insel et al., 1982; Cottreaux et al., 1984; Catapano et al., 1990) suggesting the presence of an increased activity of the hypothalamic-pituitary-adrenal (HPA) axis in these individuals. Furthermore, Gehris et al. (1990) have shown that OCD patients have significantly higher levels of urinary free cortisol excretion as compared with ageand gender-matched control subjects. Finally, higher preinfusion plasma levels of cortisol have been found in OCD patients by Rasmussen et al. (1987) who suggested that postsynaptic qadrenergic subsensitivity could explain the hyperactivity of the
223 HPA axis in OCD. Therefore, although the noradrenergic modulation of the HPA axis is quite complex and not completely understood (Plotsky et al., 1989), the concomitant modifications in melatonin and cortisol secretion that we found in our OCD patients may support the hypothesis of a noradrenergic dysfunction in OCD. On the other hand, it is also possible to hypothesize that cortisol hypersecretion by itself could result in a reduced output of melatonin from the pineal gland. In fact, it has been shown that glucocorticoids decrease the NE-stimulated melatonin secretion in vitro (Feuvre-Montange and Abu-Samra, 1983), that dexamethasone reduces plasma melatonin levels in human studies (Beck-Friis et al., 1983; Demish et al., 1988), and that the inhibition of cortisol synthesis by metyrapone results in an increased urinary excretion of melatonin (Brismar et al., 1985). Furthermore, in subjects with increased levels of endogenous glucocorticoids, such as those with Cushing’s syndrome, no nocturnal increase of melatonin levels has been observed (Soszynski et al., 1989). Therefore, the decreased production of melatonin in our OCD patients might be an epiphenomenon of their HPA axis hyperactivity. In conclusion, our data show for the first time that melatonin production is reduced in drug-free OCD patients, whereas the secretion of cortisol is increased and there is no change in the circadian rhythmicity of the two hormones. These findings require further confirmation in future studies of larger groups of subjects, since the small number of subjects in the present study could have produced a Type II error, particularly with regard to the lack of a statistically significant correlation between the AUC of melatonin or cortisol and HRSD scores. Although the pathophysiological significance of these findings remains obscure, they may contribute to further understanding of the biological aspects of OCD. References American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: American Psychiatric Press, 1987. Arendt, J.; Aldhous, M.; Bojkowski, C.; Anglish, J.; Franey, C.; Poulton, A.L.; and Skene, D. Investigation of pineal function in man. In: Reiter, R.J., and Fraschini, F., eds. Advances in Pineal Research. Vol. 2. London: John Libbey & Sons, 1987. pp. 223-229. Asberg, M.; Thor&n, P.; and Bertilsson, L. Clomipramine treatment of obsessive disorder: Biochemical and clinical aspects. Psychopharmacology Bulletin, 18: 13-21, 1982. Beck-Friis, J.; Hanssen, T.; Kjellman, B.F.; Ljunggren, J.G.; Unden, F.; and Wetterberg, L. Serum melatonin and cortisol in human subjects after the administration of dexamethasone and propranolol. Psychopharmacology Bulletin, 19:646-648, 1983. Benkelfat, C.; Mefford, I.N.; Masters, C.F.; Nordahl, T.E.; King, A.C.; Cohen, R.M.; and Murphy, D.L. Plasma catecholamines and their metabolites in obsessive-compulsive disorder. Psychiatry Research, 37:321-331, 1991. Brismar, K.; Werner, S.; Thor&n, M.; and Wetterberg, L. Metyrapone: An agent for melatonin as well as ACTH and cortisol secretion. Journal of Endocrinological Investigation, 8:91-95, 1985. Catapano, F.; Monteleone, P.; Maj, M.; and Kemali, D. Dexamethasone suppression test in patients with primary obsessive-compulsive disorder and in healthy controls. Neuropsychobiology, 23:53-56, 1990. Claustrat, B.; Chazot, G.; Bun, J.; Jordan, D.; and Sassolas, G. A chronobiological study of melatonin and cortisol secretion in depressed subjects: Plasma melatonin, a biochemical marker in major depression. Biological Psychiatry, 19: 12151228, 1984.
224
Cottreaux, J.A.; Bouvard, M.; Claustrat B.; and Juenet; C. Abnormal dexamethasone suppression test in primary obsessive-compulsive patients: A confirmatory report. Psychiatry Research, 13:157-165, 1984. Demish, L.; Demish, K.; and Nickelsen, T. Influence of dexamethasone on nocturnal melatonin production in healthy adult subjects. Journal of Pineal Research, 5:317-321, 1988. Feuvre-Montange, M., and Abu-Samra, A. Glucocorticoids inhibit the in vivo melatonin production by rat pineal gland stimulated by norepinephrine (NE) or 8-bromo-cyclic AMP. Presented at the 14th Acta Endocrinologica Satellite Symposium, Abstract 11, 1983. Gehris, T.L.; Kathol, R.G.; Black, D.W.; and Noyes, R., Jr. Urinary free cortisol levels in obsessive-compulsive disorder. Psychiatry Research, 32: 15 1-l 58, 1990. Goodman, W.K.; Rasmussen, S.A.; Price, L.H.; Mazure, C.; Heninger, G.; and Charney, D.S. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Department of Psychiatry, Yale University, New Haven, CT, 1986. Hamilton, M.A. A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23:56-62, 1960. Hollander, E.; DeCaria, C.; Nitescu, A.; Cooper, T.; Stover, B.; Klein, D.F.; and Liebowitz, M.R. Noradrenergic function in obsessive-compulsive disorder: Behavioral and neuroendocrine responses to clonidine and comparisons to healthy controls. Psychiatry Research, 37:161-177, 1991. Hollander, E.; Fay, M.; Cohen, B.; Campeas, R.; Gorman, J.M.; and Liebowitz, M.R. Serotonergic and noradrenergic sensitivity in obsessive-compulsive disorder: Behavioral findings. American Journal of Psychiatry, 145:1015-1017, 1988a. Hollander, E.; Fay, M.; and Liebowitz, M.R. Clonidine and clomipramine in obsessivecompulsive disorder. American Jornal of Psychiatry, 145:388-389, 1988b. Insel, T.R.; Kalin, N.H.; Guttmacher, L.B.; Cohen, R.M.; and Murphy, D.L. The dexamethasone suppression test in patients with primary obsessive-compulsive disorder. Psychiatry Research, 6:153-160, 1982. Insel, T.R.; Mueller, E.A.; Gillin, J.C.; Siever, L.J.; and Murphy, D.L. Biological markers in obsessive-compulsive and affective disorders. Journal of Psychiatric Research, 18:407-423, 1984. Jimerson, F.; Lynch, H.; Wurtman, R.J.; and Bunney, W.E. Urinary melatonin rhythms during sleep deprivation in depressed patients and normals. Life Sciences, 20:1501-1508, 1977. Knesevich, J.W. Successful treatment of obsessive-compulsive disorder with clonidine hydrochloride. American Journal of Psychiatry, 139:364-365, 1982. Kokkinidis, L., and Anisman, H. Dissociation of the effects of scopolamine and Damphetamine on a spontaneous alteration task. Pharmacology, Biochemistry, and Behavior, 5:293-297, 1976. Lee, M.A.; Cameron, O.G.; Gurguis, G.N.M.; Glitz, D.; Smith, C.B.; Hariharan, M.; Abelson, J.L.; and Curtis, G.C. Alpha,-adrenoceptor status in obsessive-compulsive disorder. Biological Psychiatry, 2711083-1093, 1990. Murphy, D.L.; Zohar, J.; Benkelfat, C.; Pato, M.T.; Pigott, T.A.; and Insel, T.R. Obsessive-compulsive disorder as a 5-HT subsystem-related behavioral disorder. British Journal of Psychiatry, 155 (Suppl. 8):15-24, 1989.
225 Plotsky, P.M.; Cunningham, E.T.; and Widmaier, E.P. Catecholaminergic modulation of corticotropin-releasing factor and adrenocorticotropin secretion. Endocrine Review, 10:437457, 1989.
Rasmussen, S.A.; Goodman, W.K.; Woods, S.W.; Heninger,G.R.; and Charney, D.S. Effects of yohimbine in obsessive-compulsive disorder. Psychopharmacology, 93:308-313, 1987.
Reiter, R.J. Action spectra, dose-response relationships, and temporal aspects of light’s effects on the pineal gland. Annals of the New York Academy of Sciences, 453:215-230, 1985. Reiter, R.J. Pineal melatonin: Cell biology of its synthesis and of its physiological interactions. Endocrine Review, 12:151-180, 1991. Siever, L.J.; Insel, T.R.; Jimerson, D.C.; Lake, C.R.; Uhde, T.W.; Aloi, J.; and Murphy, D.L. Growth hormone response to clonidine in obsessive-compulsive patients. British Journal of Psychiatry, 142:184-187, 1983.
Soszynski, P.; Stowinska-Srzednicka, J.; Kasperlik-Zatuska, Decreased melatonin concentration in Cushing’s syndrome.
A.; and Zgliczynski, Hormone
and
S.
Metabolic
Research, 21:673-674, 1989.
Wetterberg, L. The relationship between the pineal gland and the pituitary-adrenal axis in health, endocrine and psychiatric conditions. Psychoneuroendocrinology, 8:75-80, 1983. Zohar, J., and Insel, T.R. Obsessive-compulsive disorder: Psychobiological approaches to diagnosis, treatment, and pathophysiology. Biological Psychiatry, 22:667-687, 1987.
Psychiatry Research, 44~217-225 Elsevier
Melatonin and Cortisol Secretion in Patients With Primary 0 bsessive-Compulsive Disorder Francesco Catapano, and Dargut Kemali
Palmiero
Monteleone.
Antonio
Fuschino.
Mario Mai.
Received May 12, 1992; revised version received September 3, 1992; accepted September 19, 1992. Abstract. Plasma levels of melatonin and cortisol were measured over a 24-hour period in seven patients with primary obsessive-compulsive disorder (OCD) and seven matched healthy control subjects. In OCD patients, the 24-hour secretion of melatonin was reduced as compared with that in healthy control subjects, whereas its circadian rhythm was preserved. In addition, in OCD patients, the overall secretion of cortisol was higher than that in control subjects, but there was no change in the circadian pattern of cortisol secretion. No correlation was found between clinical parameters and hormone levels. Key Words.
Norepinephrine,
pineal
gland,
compulsions,
circadian
rhythm,
cortisol. Although the prevailing biological model of obsessive-compulsive disorder (OCD) centers on the role of serotonin (Zohar et al., 1987), several lines of evidence support the hypothesis that an abnormal noradrenergic function may be involved as well. Animal data have implicated increased norepinephrine (NE) transmission in the mediation of experimentally induced behaviors that resemble compulsions (Kokkinidis and Anisman, 1976). Clinical data have suggested that clonidine, an qadrenergic receptor agonist, has marked, even if transitory, antiobsessional effects in subjects with primary OCD (Knesevich, 1982; Hollander et al., 1988a, 19886, 1991), although it cannot be excluded that these effects are related to clonidine’s sedative effects. Finally, blunted growth hormone responses to clonidine, as well as increased levels of plasma free 3-methoxy&hydroxyphenylglycol (MHPG) and NE, have been reported in OCD patients (Siever et al., 1983; Insel et al., 1984; Rasmussen et al., 1987). These data provide support for the hypothesis that OCD is associated with both increased presynaptic noradrenergic activity and decreased postsynaptic adrenergic receptor responsiveness. However, other studies (Lee et al., 1990; Benkelfat et al., 1991; Hollander et al., 1991) have not confirmed noradrenergic dysfunction in patients with OCD. One approach to the investigation of noradrenergic transmission involves the
Francesco Catapano, M.D., is Research
Staff Psychiatrist; Palm&o Monteleone, M.D., is Temporary Research Staff Psychiatrist; Antonio Fuschino is Research Fellow; Mario Maj, M.D., is Professor of Mental Hygiene; and Dargut Kemali, M.D., is Professor of Psychiatry and Chairman, Institute of Psychiatry, First Medical School, University of Naples, Naples, Italy. (Reprint requests to Dr. P. Monteleone, Institute of Psychiatry, First Medical School, University of Naples, Largo Madonna delle Grazie, 80138 Naples, Italy.) 01651781/92/$05.00
@ 1992 Elsevier Scientific
Publishers
Ireland
Ltd.
218 assessment of the circadian rhythm of melatonin, the main secretory product of the pineal gland. Indeed, in both animal and human studies, melatonin has been shown to be secreted primarily at night under the direct influence of noradrenergic fibers that arise from the superior cervical ganglia (Arendt et al., 1987; Reiter et al., 1991). Hence, abnormalities of melatonin secretion might be related to a noradrenergic dysfunction. In the present study, we explored the circadian rhythm of melatonin in a group of drug-free primary OCD patients and in a group of matched healthy control subjects. Furthermore, since an inverse correlation between plasma cortisol and melatonin concentrations has been reported in some depressed patients (Wetterberg, 1983; Claustrat et al., 1984) we also measured plasma cortisol levels.
Methods who met DSM-III-R criteria for OCD (American Psychiatric Association, 1987), with no previous history of other psychiatric disorders, agreed to participate in the study. The OCD group consisted of four men and three women who ranged in age from 22 to Seven patients
60 years (mean 34.8, SD = 14.4). Two women were normally menstruating and were tested in the follicular phase of their menstrual cycle (days 5-9 after menses); the third female subject was postmenopausal. All patients had been drug free for at least 3 weeks. Table 1 presents the patients’ clinical characteristics, including age, sex, height, weight, and total duration of illness. At the time of the study, clinical psychopathological assessments were carried out by two psychiatrists who used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1986). The YBOCS was constructed to assess time, interference, distress, resistance, and control of obsessions and compulsions. Ratings from 0 (none) to 4 (extreme, incapacitating) are combined to arrive at total obsession and compulsion scores of O-20 each. There is also a Y-BOCS total score, which is the sum of the obsession and compulsion subscale scores and can range from 0 to 40. Moreover, although no subject met DSWIZZ-R criteria for mood disorders or had a positive family history of affective disorders, the presence of concomitant depressive symptoms was evaluated by the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960). Ratings on the Y-BOCS and the HRSD were made on the day of blood sampling. The normal control group consisted of seven healthy subjects who were individually matched to the seven patients on the following variables: age, sex, body weight, and height (Table 1). The two normally menstruating female control subjects were both tested in the follicular phase of their menstrual cycle (days 6-9 after menses). Where possible, the patient and his or her matched control subject were tested at intervals no longer than 3 weeks. This was achieved in all but one pair (#3), in which the interval was 5 weeks. Both patients and healthy volunteers received a physical examination and had routine laboratory tests to exclude metabolic alterations and any other organic disease. None of them had a family history of diabetes mellitus. They were asked to abstain from drinking alcoholic or caffeine-containing drinks for 24 hours before and during the period of the experimental sessions. Subjects were admitted to our Clinical Investigation Unit at 1700h. A standard meal was served at 1900h. At 1930h, a butterfly needle was inserted into an antecubital vein and kept patent with saline solution, which was slowly infused. At 2000h, the first blood sample was collected; thereafter subjects rested supine in dim room light (about 300 lux). At 2100h, lights were turned off, and all procedures were carried out with the aid of a red light. This light is neither bright enough nor of the proper wavelength to influence melatonin secretion (Reiter, 1985). Further blood specimens were drawn at 2200h, 2400h, OlOOh, 0200h, 03OOh, 0400h, 0600h, 0800h, 1200h, and 1600h. Subjects were allowed to sleep between 2200h and 0700h, when lights were turned on. A note was made at each sampling time as to whether subjects were asleep or awake.
F
50
50
0
N
M
M
F
F
M
M
M
25
25
27
26
26
29
22
22
0
N
0
N
0
N
0
N
N
14.4
34.8
14.2
34.8
F
32
N
0
F
35
0
M
M
60
N
M
59
0
F
Sex
Age (yr)
9.8
166.5
5.9
165.7
165
172
185
175
168
161
166
160
154
167
170
160
158
165
Height (cm)
9.5
72.0
5.4
71.0
75
68
90
80
66
4.1
8.5
9
6 -
4 -
74
62
5.7
3.2
13.0
3.5
14.2
11
11 22 27.2
13 -
17 -
30 -
18 -
3.9
10.0
7 -
17 -
13 -
9 -
7 11 -
19 -
16
9 -
6 -
11 -
HRSD total score
11
17
16 11 -
Y-BOCS compulsions score
Y-BOCS obsessions score
11
30 -
34 -
7 -
22 -
1 -
65
33 -
5 -
20 -
Y-BOCS total score
14 -
64
71
72
74
75
65
Weight (kg)
Duration of illness (yr)
Nofee.N = normal control. 0 = patient with obsessive-compulsive disorder. Y-BOCS = Yale-Brown Obsessive-Compulsive Scale. HRSD = Hamilton Rating Scale for Depression.
SD
Mean
SD
Mean
7
6
5
4
3
2
1
Pair
Table
220 Blood was collected in tubes with lithium heparin as anticoagulant. Plasma was separated by centrifugation at 3000 rpm and stored at -20 “C until assayed for melatonin and cortisol. Melatonin and cortisol assays for each patient and his or her matched control subject were run in the same lot. After extraction by diethylether, melatonin concentrations were determined by a radioimmunoassay (RIA) that used a sheep melatonin antiserum from Guildhay Antisera (University of Surrey, UK), 3H-melatonin tracer (specific activity: 85 kCi/mole; Amersham, Bucks, UK) and unlabeled melatonin (Sigma Chemical Co., St. Louis, MO, USA). Free and antibody-bound fractions of 3H-melatonin were separated using a dextran-coated charcoal solution (29&0.2%). The lower detection limit of the assay was 5 pg/ml; the upper limit was 250 pg/ml. Intra-assay and interassay coefficients of variation (CVs) were 5.1% and 9.8%, respectively. Plasma cortisol levels were determined by double-antibody RIA with commercial kits purchased from Ares-Serono (Milan, Italy). The lower detection limit of the assay was 27 nmole/ 1; the upper limit was 2700 nmole/ 1. Intra-assay and interassay CVs were 5% and 8%, respectively. Differences in hormonal secretion between OCD patients and healthy subjects were tested for statistical significance using a repeated measures two-way analysis of variance (ANOVA) with the Greenhouse-Geisser adjusted degrees of freedom and Student’s t test for paired data. Moreover, where the ANOVA indicated a significant difference between the two subject groups, the integrated areas under the curve (AUCs) were calculated and compared by Student’s t test for paired data. Relationships between AUC melatonin or AUC cortisol and psychopathological measures were evaluated by Pearson’s product-moment correlation test.
Results Table 1 shows the matching of pairs of subjects on pertinent variables. As expected, no statistically significant difference was observed between the patient group and the control group in mean age, height, or weight. The circadian rhythm of melatonin was preserved in OCD patients, but plasma levels of the indoleamine were lower than they were in healthy subjects (Fig. 1). A two-way ANOVA with repeated measures showed significant main effects for group (F=5.111;df=l, 12;p=0.04)andtime(F=23.158;df= 10, 12O;p=O.O0001), with no significant interaction effect (F= 1.340; df = 10, 120, NS), indicating that the time pattern of melatonin secretion was similar in the two groups, whereas the overall production of melatonin was significantly different. Accordingly, the melatonin AUC in healthy subjects was significantly higher than the AUC in OCD patients @ = 0.003, Student’s t test for paired data). Fig. 1 presents statistically significant differences between the two groups at the various time points. Plasma cortisol levels in OCD patients were higher than in normal control subjects (Fig. 2). A two-way ANOVA with repeated measures showed significant main effects for group (F= 8.348; df = 1, 12; p = 0.01) and time (F= 18.018; df = 10, 120; p = O.OOOl), and no significant interaction effect between time and group (F = 0.966; df = 10, 120; NS), indicating that the timing of cortisol secretion was similar between OCD patients and healthy control subjects, whereas the total secretion of the glucocorticoid was different. Indeed, the cortisol AUC in OCD patients was significantly higher than in healthy subjects (p = 0.04) (Fig. 2). Plasma cortisol levels at 20OOh,2200h, OlOOh,03OOh, and 0800h were significantly higher in OCD patients than in normal subjects (Fig. 2).
221 Fig. 1. Melatonin circadian rhythm in patients with obsessive-compulsive disorder (closed circles) and in healthy volunteers (open circles)
The dark bar indicates the dark period. Data are expressed as mean f SEM. a = p < 0.01; b = p < 0.04; c = p < 0.03; d = p < 0.003 (Student’s t test for paired data).
A negative correlation was found between the AUC of melatonin and the AUC of cortisol in both healthy subjects (r = -0.44) and OCD patients (r = -0.42), but it did not reach statistical significance. No significant correlation was found between the AUC of melatonin or cortisol and Y-BOCS total, Y-BOCS obsession, Y-BOCS compulsion, or HRSD total scores. Fig. 2. Cortisol circadian rhythm in patients with obsessive-compulsive disorder (closed circles) and in healthy volunteers (open circles)
¶0¶6¶4lSS4
6 CLOCK
6
16
I6
HOURS
The dark bar indicates the dark period. Data are expressed as mean & SEM. a = p < 0.01; b = p < 0.05; c = p < 0.02; d = p < 0.03; e = p < 0.04 (SbJdent’s t test for paired data).
222
Discussion The main finding in this study is that in OCD patients, as compared to matched healthy control subjects, the melatonin and the cortisol circadian patterns are preserved, although, respectively, at a lower and higher level. To our knowledge, this is the first study exploring melatonin and cortisol rhythms in patients with primary OCD. Because it was necessary to have a staff member enter the experimental room at each time sampling, the subject’s sleep was sometimes interrupted. However, it seems unlikely that the interruptions in sleep affected melatonin production in our subjects, since the melatonin circadian rhythm is entrained to the light-dark cycle and not to sleep (Jimerson et al., 1977). The impairment of melatonin secretion in OCD patients appears to consist essentially in a blunting of the normal rise associated with the dark condition, and may reflect a reduction in the sensitivity of pineal adrenergic receptors. Indeed, the secretion of melatonin by the pineal gland is regulated mainly by pi- and, to a lesser degree, by cx,-adrenergic receptors located on the pinealocyte membranes (Reiter, 1991). Therefore, it is possible that an increased noradrenergic tone in OCD subjects could have induced a downward regulation of postsynaptic noradrenergic receptors, leading to a reduction in melatonin output from the pineal gland. Consistent with this hypothesis, increased plasma levels of NE and MHPG have been reported in drug-free OCD patients (Siever et al., 1983; Insel et al., 1984; Rasmussen et al., 1987). Moreover, although not confirmed by all authors (Hollander et al., 1991), a decreased postsynaptic adrenergic receptor responsiveness in OCD patients has been supported by a blunted growth hormone response to clonidine (Siever et al., 1983) and an increased cortisol response to yohimbine (Rasmussen et al., 1987). Alternatively, the reduced melatonin output from the pineal gland in our patients might be an expression of a specific defect of the noradrenergic transmission in the sympathetic pathway innervating the pineal gland. However, at present, no data are available to support this hypothesis. The lowered secretion of melatonin can also be regarded as an effect of a disturbance in the brain serotonergic system, which has been repeatedly postulated in OCD (for review, see Murphy et al., 1989). In fact, the pinealocytes synthesize melatonin from pineal serotonin, which in turn is derived from systemic tryptophan (Reiter, 1991). Hence, a reduction in the availability of plasma tryptophan, alterations in the metabolic pathway leading to the synthesis of pineal serotonin, or both could result in a deficiency of melatonin production in OCD patients. Our finding of an increased secretion of cortisol in OCD patients is in line with previous reports of a failure to suppress cortisol secretion in response to the dexamethasone suppression test (DST) in some OCD patients (Asberg et al., 1982; Insel et al., 1982; Cottreaux et al., 1984; Catapano et al., 1990) suggesting the presence of an increased activity of the hypothalamic-pituitary-adrenal (HPA) axis in these individuals. Furthermore, Gehris et al. (1990) have shown that OCD patients have significantly higher levels of urinary free cortisol excretion as compared with ageand gender-matched control subjects. Finally, higher preinfusion plasma levels of cortisol have been found in OCD patients by Rasmussen et al. (1987) who suggested that postsynaptic qadrenergic subsensitivity could explain the hyperactivity of the
223 HPA axis in OCD. Therefore, although the noradrenergic modulation of the HPA axis is quite complex and not completely understood (Plotsky et al., 1989), the concomitant modifications in melatonin and cortisol secretion that we found in our OCD patients may support the hypothesis of a noradrenergic dysfunction in OCD. On the other hand, it is also possible to hypothesize that cortisol hypersecretion by itself could result in a reduced output of melatonin from the pineal gland. In fact, it has been shown that glucocorticoids decrease the NE-stimulated melatonin secretion in vitro (Feuvre-Montange and Abu-Samra, 1983), that dexamethasone reduces plasma melatonin levels in human studies (Beck-Friis et al., 1983; Demish et al., 1988), and that the inhibition of cortisol synthesis by metyrapone results in an increased urinary excretion of melatonin (Brismar et al., 1985). Furthermore, in subjects with increased levels of endogenous glucocorticoids, such as those with Cushing’s syndrome, no nocturnal increase of melatonin levels has been observed (Soszynski et al., 1989). Therefore, the decreased production of melatonin in our OCD patients might be an epiphenomenon of their HPA axis hyperactivity. In conclusion, our data show for the first time that melatonin production is reduced in drug-free OCD patients, whereas the secretion of cortisol is increased and there is no change in the circadian rhythmicity of the two hormones. These findings require further confirmation in future studies of larger groups of subjects, since the small number of subjects in the present study could have produced a Type II error, particularly with regard to the lack of a statistically significant correlation between the AUC of melatonin or cortisol and HRSD scores. Although the pathophysiological significance of these findings remains obscure, they may contribute to further understanding of the biological aspects of OCD. References American Psychiatric Association. DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: American Psychiatric Press, 1987. Arendt, J.; Aldhous, M.; Bojkowski, C.; Anglish, J.; Franey, C.; Poulton, A.L.; and Skene, D. Investigation of pineal function in man. In: Reiter, R.J., and Fraschini, F., eds. Advances in Pineal Research. Vol. 2. London: John Libbey & Sons, 1987. pp. 223-229. Asberg, M.; Thor&n, P.; and Bertilsson, L. Clomipramine treatment of obsessive disorder: Biochemical and clinical aspects. Psychopharmacology Bulletin, 18: 13-21, 1982. Beck-Friis, J.; Hanssen, T.; Kjellman, B.F.; Ljunggren, J.G.; Unden, F.; and Wetterberg, L. Serum melatonin and cortisol in human subjects after the administration of dexamethasone and propranolol. Psychopharmacology Bulletin, 19:646-648, 1983. Benkelfat, C.; Mefford, I.N.; Masters, C.F.; Nordahl, T.E.; King, A.C.; Cohen, R.M.; and Murphy, D.L. Plasma catecholamines and their metabolites in obsessive-compulsive disorder. Psychiatry Research, 37:321-331, 1991. Brismar, K.; Werner, S.; Thor&n, M.; and Wetterberg, L. Metyrapone: An agent for melatonin as well as ACTH and cortisol secretion. Journal of Endocrinological Investigation, 8:91-95, 1985. Catapano, F.; Monteleone, P.; Maj, M.; and Kemali, D. Dexamethasone suppression test in patients with primary obsessive-compulsive disorder and in healthy controls. Neuropsychobiology, 23:53-56, 1990. Claustrat, B.; Chazot, G.; Bun, J.; Jordan, D.; and Sassolas, G. A chronobiological study of melatonin and cortisol secretion in depressed subjects: Plasma melatonin, a biochemical marker in major depression. Biological Psychiatry, 19: 12151228, 1984.
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