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Dopamine and noradrenalin in the cerebrospinal fluid of schizophrenic patients
Ps.vchiorr.\~ Research.
8. 243-250
(1983)
243
Elsevier
Dopamine and Noradrenalin Schizophrenic Patients Wagner F. Gattaz. Peter Helmut Beckmann Received 1982.
Mu>~28, 1982;
revised
Riederer,
version
in the Cerebrospinal
Gavin
received
P. Reynolds,
Seppremher
20, 1982;
Daher
acwppred
Fluid of
Gattaz,
Drcrmher
and
13,
Abstract. Concentrations of both dopamine (DA) and noradrenalin (NA) were determined in the cerebrospinal fluid (CSF) of schizophrenic patients with and without neuroleptic treatment and in healthy controls. No significant differences were found between unmedicated patients and controls for either DA or NA. Patients receiving neuroleptics showed significantly higher levels of both DA and NA in the CSF. These results suggest that the reported findings of increased NA in the CSF and increased DA and NA in the brain of schizophrenic patients could be due, at least in part, to the effects of neuroleptic drugs.
Key Words. Schizophrenia.
cerebrospinal
fluid. dopamine.
noradrenalin
The catecholamines dopamine (DA) and noradrenalin (NA) have frequently been implicated in the etiolgoy of the major psychoses. A hypothetical hyperactivity of the dopaminergic system in schizophrenia has been proposed, based upon the observations that (1) virtually all antipsychotic drugs have a DA receptor blocking effect and (2) DA agonists, e.g., amphetamine. are likely to produce a schizophrenia-like psychosis in certain individuals. NA has recently been reported to be increased in the cerebrospinal fluid (CSF) of schizophrenic patients by two laboratories (Comes et al., 1980; Lake et al., 1980; Sternberg et al.. 1981). This is in line with earlier findings of increased NA concentrations in the brain of deceased schiz.ophrenics (Farley et al., 1978; Bird et al.. 1979). The purpose of the present study was to determine the levels of both catecholamines in the CSF of schizophrenic patients and healthy controls in order to investigate further their role in the disease, their interrelationship, and the effect of neuroleptic drugs on their concentrations. To our knowledge this is the first report of concentrations of DA in the CSF of schizophrenic patients compared to controls. The study is
Wagner F. Gattal. M.D.. is Visiting Professor. Psychiatric Clinic ofthe Central Institute of Mental Health. Mannheim. F. R.G.. and Assistant Professor of Psychiatry. Faculdade de Medicina da Fundacao do ABC. Sao Paula. Braril. Peter Riederer. Ph.D.. is Assistant Professorand Head. Neurochemistry Group. Ludwig Boltmann Inatttuteof Clinical Neurobiology. Lainl-Hospital, Vienna. Austria. Gavin P. Reynolds. Ph.D., is at the MRC Neurochemical Pharmacology Unit, Addenbrooke’s Hospital. Cambridge. England. Daher Gattaz. M.D.. is Clinical Director. Clinica Borda do Campo, Sao Paulo, Brazil. Helmut Beckmann. M.D., is Professor. Central Instituteof Mental Health. Mannheim. F.R.G. (Reprint requeststo Dr. W.F. Gattar. R. Leoncio de Carvalho 254:31, 04003 S;io Paula, SP. Braril.) 0165-I 78 I ‘83 0000-0000!$3.00
a Elsevier Science Publishers
244
one part (Gattaz
of a larger et al.. 1982a.
biological 19826).
investigation
which
has been described
elsewhere
Methods The sample comprises 2X paranoid schizophrenic patients (all Caucasian males. mean age 30.6 + SD 8.0 years) consecutively admitted at the Clinica Borda do Campo (Sao Paulo,Brazil) and I5 controls (13 males and 2 females. mean age 35.0 + SD 15.7 years). Since the results obtained in the two female subjects were similar to those in males, data were considered together. Patients were diagnosed according to the Research Diagnostic Criteria (Spitzer et al.. 1975). Two experienced psychiatrists independently evaluated their psychopathological state by means of the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham. 1962) immediately before the lumbar puncture. Fifteen patients were under treatment with neuroleptic drugs (butyrophenones and phenothia7ines) for at least 3 weeks (mean dose * SD in chlorpromazine equivalents q 585 + 755 mg. day) (see Table I ). Thirteen patients were unmedicated for a period of at least 4 weeks before the study. The data for patients who had been under treatment with neuroleptics for at least 3 weeks or who had been drug free for at least 4 weeks were collected during the time in which the patient was observed by one of us after the patient’s inclusion in the study. Both subgroups of patients were on a free standardized diet. (See Table 2 for further detatls concerning the pattent sample.)
Table 1 . Pharmacological neuroleptics
data in the group
Dose in chlorpromazine equivalents)
(mg/day Patient
Drug
4 6 7 10 16 17 18 19 20 21 25 26 27 28 29
Haloperidol Haloperidol Haloperldol Haloperrdol Chlorpromazrne Haloperrdol Haloperldol Haloperrdol Haloperidol Haloperidol Haloperldol Haloperrdol Haloperrdol Haloperidol Fluphenazine
of 15 patients
Controls were subjects with nonspecific dizziness) who required a lumbar puncture at the time of the lumbar puncture. CSF was obtained by lumbar puncture a.m.. after subjects had fasted for 12 hours CSF were removed without additions. To gently mixed and then immediately fro/en clinical work was completed, samples were then stored at -70°C until analyzed.
312 2812 625 1875 600 187 625 312 187 187 187 187 187 187 298
neurological for diagnostic
treated
with
CSF
NA
CSF
DA
(pg/
ml)
(pg/
ml)
0.249 0.103 0.097 0 206 0.136 0.224 0 305 0.244 0.224 0.109 0.314 0.224 0.308 0 237 0 180
0.294 0.190 0.222 0.286 0.478 1.660 0.731 1.950 0.507 0.181 0.244 0.543 0.252 0.228 0.100
symptomatology (e.g.. headaches or purposes. Controls were unmedicated
with subjects in a sitting position between 9 and IO and had been at bed rest for IO hours. Sixteen ml of avoid rostral-caudai gradient effects. samples were on dry ice and stored in a freerer at -50°C. When the transported from Brazil to Germany on dry ice and
245 Table 2. Comparison of the ethnographic and psychopathological variables between patients on and off neuroleotic drugs Schizophrenics on drugs (n= 15) Variables
Mean
Age (years)
31.8
SD 10.1
Schizophrenics off drugs (n = 13) Mean
SD
29.3
4.4
Age at onset of illness (years) Duration
20.6
5.4
21.8
3.8
10.8
6.8
8.3
4.5
7.3
of illness
(years) No. of
13.6
10.0
7.6
ANDP
7.0
4.5
5.3
ANER
12.9
4.6
13.8
4.0
THOT
14.5
7.6
15.6
5.7
ACTV
3.8
1 .8
6.4
3.1
HOST
6.4
4.4
8.5
4.7
49.7
9.1
hospitalizations
TOTAL
44.6
1 1 .4
1 .7
’
Scores of the Brief Psychlatm Rating Scale ANDP = Anxlety/depressmn. ANER = anergla; THOT = thought dmurbance. ACTV = actwamn; HOST hostlIe/ suspiciousness. 1. p < 0.05 (two-tailed Mann-Whitney U test1
Catecholamines were determined according to the method described by Felice et al. (1978). with some modifications. Briefly, the catechols were adsorbed to 25 mg acid-washed A1203 at pH 8.6. One ml of deproteinized CSF was taken. After washing with Tris-buffer. the catechols were eluted with 100 ~1 of a solution containing0.4 M acetic acid ( I mM NazS2Os= 9: I). Fifty ~1 of the eluate were injected into a high performance liquid chromatography (H PLC) system with a Nucleosil 10 SA column (25 x 0.46 cm) and electrochemical detection (TL-3 BAS: I nA; V). The mobile phase consisted of a citric buffer, pH 5.2 (flow 0.5 ml/ minute). Dihydroxybenzylamine was used as internal standard. A possible interference of neuroleptics on the determinations has been investigated through the addition of haloperidol. chlorpromazine, and fluphenazine direcr!,, on the column, in doses up to IO-fold the equivalent of the mean doses in the present sample. No peak formation has been observed for these drugs. A possible interference of dihydroxyphenylglycol on the determinations is mitigated against by our failure to detect the presence of this substance in human CSF. The biochemical determinations were performed without knowledge of the origin of each sample. Nonparametric tests (Kruskal-Walhs one-way analysis of variance. Mann-Whitney U test and Spearman correlation coefficients, all two-tailed) were used for the statistical evaluation of the data.
Results
One-way analysis of variance (ANOVA) unmedicated patients showed intergroup 0.006).
of control differences
group, medicated patients, and for DA (r, = 0.002) and NA (JJ =
246 NA. There was a tendency for NA to be higher in unmedicated patients as compared to healthy controls, but this was not statistically significant (0.05 < /I < 0.10). However. patients receiving neuroleptics had a significantly higher NA concentration than controls (11< 0.01) (Table 3. Fig. I ).
DA. No difference was found in the CSF DA concentration between healthy controls and unmedicated schizophrenic patients. Conversely, patients receiving neuroleptic treatment had clearly higher DA levels than controls (17< 0.00 I ) and than patients not receiving neuroleptics (/I < 0.0 I ) (Table 3: Kg. 2).
Table 3. Concentrations of noradrenalin (DA) (na/ml * S D 1 in schizoohrenics
(NA) and dopamine and controls
Schizophrenics Control group (/I q 15) NA
0133too37
DA
0207
Mann-Whitney 2 j, 3
: 0 01
11 ,:‘O
001
: 1 test compared compared
+0263 (two
talled)
to controls to controls
Schrzophrenics
off drugs
((7 = 15)
0.163 * 0.044’ 0.200 * 0.124
0.2 10 * 0.0732 0.524 f 0.54g3
1 !’ ~. 0 1 compared and and
j:
on drugs
(G = 13)
‘0
1 compared
,’ e: 0 01
compared
to controls to patents to patlents
off drugs off drugs
CSF levels of DA correlated significantly with CSF levels of N A (r, = 0.43, p < 0.0 1). No significant correlations were found between CSF levels of the monoamines and age. duration of illness. number of psychiatric hospitalizations, dose of neuroleptics. or BPRS psychopathological items. Discussion
Experimental evidence indicates that CSF levels of TVAreflect to a considerableextent the noradrenergic activity in the brain (Ziegler et al.. 1977). Because of the vicinity of the caudate nucleus to the cerebral ventricles. it is not unlikely that the same holds true for CSF levels of DA. 7hus. the in\.estigation of the levels of both catecholamines in the CSF may provide a reliable approach to the study of monoaminergic activity in the CNS. It is noteworthy that in our group of schizophrenics not receiving neuroleptic treatment we could not replicate the findings of increased NA levels in the CSF as reported in the literature. Games et al. (1980) found increased NA in the CSF of I I chronic schizophrenic patients. However. a drug effect on the results could not be excluded. since all patients studied were on neurolcptic treatment at the time of the lumbar puncture. Two further studies carried out by another research group (Lake et al., 1980: Sternberg et al.. 1981) reported increased NA levels in the CSF of schizophrenic patients who had been drug free for 2 or 3 weeks. In our own patients who had been drug free for at least 4 weeks. we noted a trend toward higher CSF levels of NA. However. in \iew of the marked increase of NA levels in our drug-treated patients. it
247 Fig. 1. Levels
of NA in CSF in schizophrenic
patients
and controls
0360. 03l.O.~ 0320.. 0 300 ” 0280.0260-.
_
02m 0220.-
: + :
l
. . . .
0200.. 0180-. 0160-
. .
-
--___-m +
n+m p-_;__ ’
-+--I
OlLO
0120.. 0100 t
: . .:
-
;
I CONTROLS
I = controls:
II = schmphretuc
patients
off neuroleptlc
PATIENTS
drugs; III = schwophrenkc
patents
on neuroleptlc
drugs
might be speculated that higher NA levels in patients who have been drug free for a relatively short period represent a late effect of neuroleptic treatment. Nevertheless. this suggestion is at variance with the results of the longitudinal study by Sternberget al. (1981), who instead observed a decrement of CSF NA in a group of schizophrenics studied before and after neuroleptic treatment. To our knowledge the finding of similar concentrations of CSF DA in drug-free schizophrenics and healthy controls has not yet been reported in the literature. While not contradicting the DA hypothesis of schizophrenia, the present finding does not readily support the hypothesis. The turnover of catecholamines in the brain can also be studied through the investigation of their CSF metabolites. Homovanillic acid (HVA) and 3-methoxy-4hydroxyphenylglycol (MHPG), the major CSF metabolites of DA and NA, respectively, have been determined in the same sample described here. As reported elsewhere (Gattaz et al., 19826), no significant differences were found among patients with and without neuroleptics and controls. In the present study, no correlations were found
248 Fig. 2. Levels of DA in CSF in schizophrenic
patients and controls
DA ing/mll
2000 t 17oot
1200
0 750
.-
+
0 700 -0 650 -0 600 -f t
c550-0 500..
-__---
m
045% GLOO-~-
II+In
0 350 ~0 300..
f
0 250--
.
+ ++
: 0 200..
----_I
. :
n______
1’
drugs,
Ill
3 150~. : . .. ..
0 loo--
.
I
controls,
II
schszophrerx
pat,ents
off neuroleptx
schizophrentc
patients
on neuroleptlc
drugs
between the concentrations of the parent amines and their metabolites in CSF. The lack of correlations. which has been previously observed by other authors in the case of NA-M H PC (Post et al., 1978; Sternberg et al., I98 I), has been suggested as possibly attributable to differences in half-life and transport characteristics. Furthermore. our finding of a positive correlation between CSF levels of NA and DA supports a relationship between the dopaminergic and noradrenergic systems in the central nervous system (Pradham and Bose, 1978). Our results indicate that neuroleptic treatment might enhance theconcentrations of both NA and DA in the CSF. This finding is in agreement with animal studies in which neuroleptics were shown to increase the concentrations of NA and DA in different areas of the brain. probably through a positive feedback mechanism after blockade of pre- or postsynaptic receptors (for review. see Bartholini et al.. 1976). Taken together,
249
these data suggest that the findings of increased DA and NA in specific brain areas of deceased schizophrenic patients (Bird et al.. 1977, 1979; Farley et al.. 1978) could be due, at least in part, to the chronic studies with a rigorous assessment tive conclusions can be drawn.
intake of neuroleptic drugs. However, longitudinal of neuroleptic intake will be needed before defini-
We are indebted to Dipl-Psych. Wolfgang Stramke in the statistical evaluation of our data through the SPSS program.
Acknowledgments.
assistance
for his skillful
References Bartholini. G.. Stadler, H., Gadea Ciria, M., and Lloyd, K.G. The use of the push-pull cannula to estimate the dynamics of acetylcholine and catecholamines within various brain areas. Neuropharmac~o/ogv, 15, 5 I5 ( 1976). Bird, E.D.. Barnes. J., Iversen. L.L.. Spokes. E.G.. Mackay, A.V.P., and Shepherd. M. Increased brain dopamine and reduced glutamic acid decarboxylase and choline acetyl transferase activity in schizophrenia and related psychoses. Lancer. II, I I57 (1977). Bird, E. D.. Spokes, E.G., and Iversen, L.L. Brain norepinephrine and dopamine in schirophrenia. Science. 204, 93 (1979). Farley, I.F.. Price. K.S., McCullough, E.. Deck, J.H.N.. Hordynski, W., and Hornykiewicz, 0. Norepinephrine in chronic paranoid schizophrenia: Above-normal levels in limbic forebrain. Science, 200,456 (1978). Felice, L.J.. Felice. J.D., and Kissinger, P.T. Determination ofcatecholamines in rat brain parts by reverse-phase ion-pair liquid chromatography. Journal of Neuroc~hemistr~~. 31, 1461 (1978).
Gattaz. W.F., Gattaz, D.. and Beckmann. Archiv,/Ur
Pswhiatrie
H. Glutamate
und Nervenkrankheiten,
in schizophrenics
and healthy controls.
231, 221 (1982a).
Gattaz, W.F., Waldmeier, P., and Beckmann, H. CSF monoamine metabolites in schizophrenic patients. Acta Psychiarrica Scandinavica. 66, 350 ( 19826). Gomes, U.C.R.. Shanley, B.C., Potgieter. L., and Roux, J.T. Noradrenergic overactivity in chronic schizophrenia: Evidence based on cerebrospinal fluid noradrenaline and cyclic nucleotide concentrations. British Journal of Ps~~c,hiarr_,~.137, 346 ( 1980). Lake. C.R.. Sternberg, D.E., van Kammen. D.P.. Ballenger. J.C., Ziegler, M.G., Post. R.M., Kopin. I.J.. and Bunney. W.E. Schizophrenia: Elevated cerebrospinal fluid norepinephrine. Science, 207, 33 I ( 1980). Overall, J.E., and Gorham. D.R. The Brief Psychiatric Rating Scale. Ps~~chological Reports, 10, 799 (1962).
Post, R.M.. Goodwin,
Lake, C.R., Jimerson, D.C.. Bunney, W.E.. Jr.. Wood, J.H., Ziegler, M.G.. and F.K. Cerebrospinal fluid norepinephrine in affective illness. American Journalqf
Psjsc,hiarr,v, 135, 907 (1978).
Pradham. S.N.. and Bose, S. Interactions among central neurotransmitters. In: Lipton, M.A.. DiMascio. A., and Killam, K.F., eds. Ps~~hopharmac,o/ogl,; A Generation qf’ Progress. Raven Press. New York, p. 27 1 (1978). Spitzer. R.L.. Endicott. J., and Robins. E. Research Diagnostic Crireria. Instrument No. 58. New York State Psychiatric Institute. New York (1975). Sternberg, D.E.. van Kammen. D.P., Lake, C.R.. Ballenger, J.C.. Marder, S.R.. and Bunney, W.E., Jr. The effect of pimozide on CSF norepinephrine in schizophrenia. American Journal cf P.cyhiarr,~,
138, 1045 (1981).
Ziegler. M.G.. Lake, C.R., Wood, J.H.. Brooks, B. R., and Ebert. M. H. Relationship between norepinephrine in blood and cerebrospinal fluid in the presence of a blood-cerebrospinal fluid barrier for norepinephrine. Journal qf‘ Neurochemistrjs, 28,677 (1977).
250 Addendum After the submission of this article, D. Kemali, M. Del Vecchio, and M. Maj (Biological Ps?~chiatry, 17, 7 I I, 1982) reported increased NA levels in the CSF of 8 schizophrenics who had been drug free for 15 days as compared to IO healthy controls. No significant differences were found in the CSF DA concentrations between patients and controls. We are presently investigating the NA and DA concentrations in the CSF of schizophrenics before and after 3 weeks of treatment with haloperidol (mean 25 mgiday). The preliminary evaluation of the first nine patients showed that NA increased significantly in sellen patients after 3 weeks on neuroleptics, but no consistent trend could be observed for the DA concentrations in this small sample.
8. 243-250
(1983)
243
Elsevier
Dopamine and Noradrenalin Schizophrenic Patients Wagner F. Gattaz. Peter Helmut Beckmann Received 1982.
Mu>~28, 1982;
revised
Riederer,
version
in the Cerebrospinal
Gavin
received
P. Reynolds,
Seppremher
20, 1982;
Daher
acwppred
Fluid of
Gattaz,
Drcrmher
and
13,
Abstract. Concentrations of both dopamine (DA) and noradrenalin (NA) were determined in the cerebrospinal fluid (CSF) of schizophrenic patients with and without neuroleptic treatment and in healthy controls. No significant differences were found between unmedicated patients and controls for either DA or NA. Patients receiving neuroleptics showed significantly higher levels of both DA and NA in the CSF. These results suggest that the reported findings of increased NA in the CSF and increased DA and NA in the brain of schizophrenic patients could be due, at least in part, to the effects of neuroleptic drugs.
Key Words. Schizophrenia.
cerebrospinal
fluid. dopamine.
noradrenalin
The catecholamines dopamine (DA) and noradrenalin (NA) have frequently been implicated in the etiolgoy of the major psychoses. A hypothetical hyperactivity of the dopaminergic system in schizophrenia has been proposed, based upon the observations that (1) virtually all antipsychotic drugs have a DA receptor blocking effect and (2) DA agonists, e.g., amphetamine. are likely to produce a schizophrenia-like psychosis in certain individuals. NA has recently been reported to be increased in the cerebrospinal fluid (CSF) of schizophrenic patients by two laboratories (Comes et al., 1980; Lake et al., 1980; Sternberg et al.. 1981). This is in line with earlier findings of increased NA concentrations in the brain of deceased schiz.ophrenics (Farley et al., 1978; Bird et al.. 1979). The purpose of the present study was to determine the levels of both catecholamines in the CSF of schizophrenic patients and healthy controls in order to investigate further their role in the disease, their interrelationship, and the effect of neuroleptic drugs on their concentrations. To our knowledge this is the first report of concentrations of DA in the CSF of schizophrenic patients compared to controls. The study is
Wagner F. Gattal. M.D.. is Visiting Professor. Psychiatric Clinic ofthe Central Institute of Mental Health. Mannheim. F. R.G.. and Assistant Professor of Psychiatry. Faculdade de Medicina da Fundacao do ABC. Sao Paula. Braril. Peter Riederer. Ph.D.. is Assistant Professorand Head. Neurochemistry Group. Ludwig Boltmann Inatttuteof Clinical Neurobiology. Lainl-Hospital, Vienna. Austria. Gavin P. Reynolds. Ph.D., is at the MRC Neurochemical Pharmacology Unit, Addenbrooke’s Hospital. Cambridge. England. Daher Gattaz. M.D.. is Clinical Director. Clinica Borda do Campo, Sao Paulo, Brazil. Helmut Beckmann. M.D., is Professor. Central Instituteof Mental Health. Mannheim. F.R.G. (Reprint requeststo Dr. W.F. Gattar. R. Leoncio de Carvalho 254:31, 04003 S;io Paula, SP. Braril.) 0165-I 78 I ‘83 0000-0000!$3.00
a Elsevier Science Publishers
244
one part (Gattaz
of a larger et al.. 1982a.
biological 19826).
investigation
which
has been described
elsewhere
Methods The sample comprises 2X paranoid schizophrenic patients (all Caucasian males. mean age 30.6 + SD 8.0 years) consecutively admitted at the Clinica Borda do Campo (Sao Paulo,Brazil) and I5 controls (13 males and 2 females. mean age 35.0 + SD 15.7 years). Since the results obtained in the two female subjects were similar to those in males, data were considered together. Patients were diagnosed according to the Research Diagnostic Criteria (Spitzer et al.. 1975). Two experienced psychiatrists independently evaluated their psychopathological state by means of the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham. 1962) immediately before the lumbar puncture. Fifteen patients were under treatment with neuroleptic drugs (butyrophenones and phenothia7ines) for at least 3 weeks (mean dose * SD in chlorpromazine equivalents q 585 + 755 mg. day) (see Table I ). Thirteen patients were unmedicated for a period of at least 4 weeks before the study. The data for patients who had been under treatment with neuroleptics for at least 3 weeks or who had been drug free for at least 4 weeks were collected during the time in which the patient was observed by one of us after the patient’s inclusion in the study. Both subgroups of patients were on a free standardized diet. (See Table 2 for further detatls concerning the pattent sample.)
Table 1 . Pharmacological neuroleptics
data in the group
Dose in chlorpromazine equivalents)
(mg/day Patient
Drug
4 6 7 10 16 17 18 19 20 21 25 26 27 28 29
Haloperidol Haloperidol Haloperldol Haloperrdol Chlorpromazrne Haloperrdol Haloperldol Haloperrdol Haloperidol Haloperidol Haloperldol Haloperrdol Haloperrdol Haloperidol Fluphenazine
of 15 patients
Controls were subjects with nonspecific dizziness) who required a lumbar puncture at the time of the lumbar puncture. CSF was obtained by lumbar puncture a.m.. after subjects had fasted for 12 hours CSF were removed without additions. To gently mixed and then immediately fro/en clinical work was completed, samples were then stored at -70°C until analyzed.
312 2812 625 1875 600 187 625 312 187 187 187 187 187 187 298
neurological for diagnostic
treated
with
CSF
NA
CSF
DA
(pg/
ml)
(pg/
ml)
0.249 0.103 0.097 0 206 0.136 0.224 0 305 0.244 0.224 0.109 0.314 0.224 0.308 0 237 0 180
0.294 0.190 0.222 0.286 0.478 1.660 0.731 1.950 0.507 0.181 0.244 0.543 0.252 0.228 0.100
symptomatology (e.g.. headaches or purposes. Controls were unmedicated
with subjects in a sitting position between 9 and IO and had been at bed rest for IO hours. Sixteen ml of avoid rostral-caudai gradient effects. samples were on dry ice and stored in a freerer at -50°C. When the transported from Brazil to Germany on dry ice and
245 Table 2. Comparison of the ethnographic and psychopathological variables between patients on and off neuroleotic drugs Schizophrenics on drugs (n= 15) Variables
Mean
Age (years)
31.8
SD 10.1
Schizophrenics off drugs (n = 13) Mean
SD
29.3
4.4
Age at onset of illness (years) Duration
20.6
5.4
21.8
3.8
10.8
6.8
8.3
4.5
7.3
of illness
(years) No. of
13.6
10.0
7.6
ANDP
7.0
4.5
5.3
ANER
12.9
4.6
13.8
4.0
THOT
14.5
7.6
15.6
5.7
ACTV
3.8
1 .8
6.4
3.1
HOST
6.4
4.4
8.5
4.7
49.7
9.1
hospitalizations
TOTAL
44.6
1 1 .4
1 .7
’
Scores of the Brief Psychlatm Rating Scale ANDP = Anxlety/depressmn. ANER = anergla; THOT = thought dmurbance. ACTV = actwamn; HOST hostlIe/ suspiciousness. 1. p < 0.05 (two-tailed Mann-Whitney U test1
Catecholamines were determined according to the method described by Felice et al. (1978). with some modifications. Briefly, the catechols were adsorbed to 25 mg acid-washed A1203 at pH 8.6. One ml of deproteinized CSF was taken. After washing with Tris-buffer. the catechols were eluted with 100 ~1 of a solution containing0.4 M acetic acid ( I mM NazS2Os= 9: I). Fifty ~1 of the eluate were injected into a high performance liquid chromatography (H PLC) system with a Nucleosil 10 SA column (25 x 0.46 cm) and electrochemical detection (TL-3 BAS: I nA; V). The mobile phase consisted of a citric buffer, pH 5.2 (flow 0.5 ml/ minute). Dihydroxybenzylamine was used as internal standard. A possible interference of neuroleptics on the determinations has been investigated through the addition of haloperidol. chlorpromazine, and fluphenazine direcr!,, on the column, in doses up to IO-fold the equivalent of the mean doses in the present sample. No peak formation has been observed for these drugs. A possible interference of dihydroxyphenylglycol on the determinations is mitigated against by our failure to detect the presence of this substance in human CSF. The biochemical determinations were performed without knowledge of the origin of each sample. Nonparametric tests (Kruskal-Walhs one-way analysis of variance. Mann-Whitney U test and Spearman correlation coefficients, all two-tailed) were used for the statistical evaluation of the data.
Results
One-way analysis of variance (ANOVA) unmedicated patients showed intergroup 0.006).
of control differences
group, medicated patients, and for DA (r, = 0.002) and NA (JJ =
246 NA. There was a tendency for NA to be higher in unmedicated patients as compared to healthy controls, but this was not statistically significant (0.05 < /I < 0.10). However. patients receiving neuroleptics had a significantly higher NA concentration than controls (11< 0.01) (Table 3. Fig. I ).
DA. No difference was found in the CSF DA concentration between healthy controls and unmedicated schizophrenic patients. Conversely, patients receiving neuroleptic treatment had clearly higher DA levels than controls (17< 0.00 I ) and than patients not receiving neuroleptics (/I < 0.0 I ) (Table 3: Kg. 2).
Table 3. Concentrations of noradrenalin (DA) (na/ml * S D 1 in schizoohrenics
(NA) and dopamine and controls
Schizophrenics Control group (/I q 15) NA
0133too37
DA
0207
Mann-Whitney 2 j, 3
: 0 01
11 ,:‘O
001
: 1 test compared compared
+0263 (two
talled)
to controls to controls
Schrzophrenics
off drugs
((7 = 15)
0.163 * 0.044’ 0.200 * 0.124
0.2 10 * 0.0732 0.524 f 0.54g3
1 !’ ~. 0 1 compared and and
j:
on drugs
(G = 13)
‘0
1 compared
,’ e: 0 01
compared
to controls to patents to patlents
off drugs off drugs
CSF levels of DA correlated significantly with CSF levels of N A (r, = 0.43, p < 0.0 1). No significant correlations were found between CSF levels of the monoamines and age. duration of illness. number of psychiatric hospitalizations, dose of neuroleptics. or BPRS psychopathological items. Discussion
Experimental evidence indicates that CSF levels of TVAreflect to a considerableextent the noradrenergic activity in the brain (Ziegler et al.. 1977). Because of the vicinity of the caudate nucleus to the cerebral ventricles. it is not unlikely that the same holds true for CSF levels of DA. 7hus. the in\.estigation of the levels of both catecholamines in the CSF may provide a reliable approach to the study of monoaminergic activity in the CNS. It is noteworthy that in our group of schizophrenics not receiving neuroleptic treatment we could not replicate the findings of increased NA levels in the CSF as reported in the literature. Games et al. (1980) found increased NA in the CSF of I I chronic schizophrenic patients. However. a drug effect on the results could not be excluded. since all patients studied were on neurolcptic treatment at the time of the lumbar puncture. Two further studies carried out by another research group (Lake et al., 1980: Sternberg et al.. 1981) reported increased NA levels in the CSF of schizophrenic patients who had been drug free for 2 or 3 weeks. In our own patients who had been drug free for at least 4 weeks. we noted a trend toward higher CSF levels of NA. However. in \iew of the marked increase of NA levels in our drug-treated patients. it
247 Fig. 1. Levels
of NA in CSF in schizophrenic
patients
and controls
0360. 03l.O.~ 0320.. 0 300 ” 0280.0260-.
_
02m 0220.-
: + :
l
. . . .
0200.. 0180-. 0160-
. .
-
--___-m +
n+m p-_;__ ’
-+--I
OlLO
0120.. 0100 t
: . .:
-
;
I CONTROLS
I = controls:
II = schmphretuc
patients
off neuroleptlc
PATIENTS
drugs; III = schwophrenkc
patents
on neuroleptlc
drugs
might be speculated that higher NA levels in patients who have been drug free for a relatively short period represent a late effect of neuroleptic treatment. Nevertheless. this suggestion is at variance with the results of the longitudinal study by Sternberget al. (1981), who instead observed a decrement of CSF NA in a group of schizophrenics studied before and after neuroleptic treatment. To our knowledge the finding of similar concentrations of CSF DA in drug-free schizophrenics and healthy controls has not yet been reported in the literature. While not contradicting the DA hypothesis of schizophrenia, the present finding does not readily support the hypothesis. The turnover of catecholamines in the brain can also be studied through the investigation of their CSF metabolites. Homovanillic acid (HVA) and 3-methoxy-4hydroxyphenylglycol (MHPG), the major CSF metabolites of DA and NA, respectively, have been determined in the same sample described here. As reported elsewhere (Gattaz et al., 19826), no significant differences were found among patients with and without neuroleptics and controls. In the present study, no correlations were found
248 Fig. 2. Levels of DA in CSF in schizophrenic
patients and controls
DA ing/mll
2000 t 17oot
1200
0 750
.-
+
0 700 -0 650 -0 600 -f t
c550-0 500..
-__---
m
045% GLOO-~-
II+In
0 350 ~0 300..
f
0 250--
.
+ ++
: 0 200..
----_I
. :
n______
1’
drugs,
Ill
3 150~. : . .. ..
0 loo--
.
I
controls,
II
schszophrerx
pat,ents
off neuroleptx
schizophrentc
patients
on neuroleptlc
drugs
between the concentrations of the parent amines and their metabolites in CSF. The lack of correlations. which has been previously observed by other authors in the case of NA-M H PC (Post et al., 1978; Sternberg et al., I98 I), has been suggested as possibly attributable to differences in half-life and transport characteristics. Furthermore. our finding of a positive correlation between CSF levels of NA and DA supports a relationship between the dopaminergic and noradrenergic systems in the central nervous system (Pradham and Bose, 1978). Our results indicate that neuroleptic treatment might enhance theconcentrations of both NA and DA in the CSF. This finding is in agreement with animal studies in which neuroleptics were shown to increase the concentrations of NA and DA in different areas of the brain. probably through a positive feedback mechanism after blockade of pre- or postsynaptic receptors (for review. see Bartholini et al.. 1976). Taken together,
249
these data suggest that the findings of increased DA and NA in specific brain areas of deceased schizophrenic patients (Bird et al.. 1977, 1979; Farley et al.. 1978) could be due, at least in part, to the chronic studies with a rigorous assessment tive conclusions can be drawn.
intake of neuroleptic drugs. However, longitudinal of neuroleptic intake will be needed before defini-
We are indebted to Dipl-Psych. Wolfgang Stramke in the statistical evaluation of our data through the SPSS program.
Acknowledgments.
assistance
for his skillful
References Bartholini. G.. Stadler, H., Gadea Ciria, M., and Lloyd, K.G. The use of the push-pull cannula to estimate the dynamics of acetylcholine and catecholamines within various brain areas. Neuropharmac~o/ogv, 15, 5 I5 ( 1976). Bird, E.D.. Barnes. J., Iversen. L.L.. Spokes. E.G.. Mackay, A.V.P., and Shepherd. M. Increased brain dopamine and reduced glutamic acid decarboxylase and choline acetyl transferase activity in schizophrenia and related psychoses. Lancer. II, I I57 (1977). Bird, E. D.. Spokes, E.G., and Iversen, L.L. Brain norepinephrine and dopamine in schirophrenia. Science. 204, 93 (1979). Farley, I.F.. Price. K.S., McCullough, E.. Deck, J.H.N.. Hordynski, W., and Hornykiewicz, 0. Norepinephrine in chronic paranoid schizophrenia: Above-normal levels in limbic forebrain. Science, 200,456 (1978). Felice, L.J.. Felice. J.D., and Kissinger, P.T. Determination ofcatecholamines in rat brain parts by reverse-phase ion-pair liquid chromatography. Journal of Neuroc~hemistr~~. 31, 1461 (1978).
Gattaz. W.F., Gattaz, D.. and Beckmann. Archiv,/Ur
Pswhiatrie
H. Glutamate
und Nervenkrankheiten,
in schizophrenics
and healthy controls.
231, 221 (1982a).
Gattaz, W.F., Waldmeier, P., and Beckmann, H. CSF monoamine metabolites in schizophrenic patients. Acta Psychiarrica Scandinavica. 66, 350 ( 19826). Gomes, U.C.R.. Shanley, B.C., Potgieter. L., and Roux, J.T. Noradrenergic overactivity in chronic schizophrenia: Evidence based on cerebrospinal fluid noradrenaline and cyclic nucleotide concentrations. British Journal of Ps~~c,hiarr_,~.137, 346 ( 1980). Lake. C.R.. Sternberg, D.E., van Kammen. D.P.. Ballenger. J.C., Ziegler, M.G., Post. R.M., Kopin. I.J.. and Bunney. W.E. Schizophrenia: Elevated cerebrospinal fluid norepinephrine. Science, 207, 33 I ( 1980). Overall, J.E., and Gorham. D.R. The Brief Psychiatric Rating Scale. Ps~~chological Reports, 10, 799 (1962).
Post, R.M.. Goodwin,
Lake, C.R., Jimerson, D.C.. Bunney, W.E.. Jr.. Wood, J.H., Ziegler, M.G.. and F.K. Cerebrospinal fluid norepinephrine in affective illness. American Journalqf
Psjsc,hiarr,v, 135, 907 (1978).
Pradham. S.N.. and Bose, S. Interactions among central neurotransmitters. In: Lipton, M.A.. DiMascio. A., and Killam, K.F., eds. Ps~~hopharmac,o/ogl,; A Generation qf’ Progress. Raven Press. New York, p. 27 1 (1978). Spitzer. R.L.. Endicott. J., and Robins. E. Research Diagnostic Crireria. Instrument No. 58. New York State Psychiatric Institute. New York (1975). Sternberg, D.E.. van Kammen. D.P., Lake, C.R.. Ballenger, J.C.. Marder, S.R.. and Bunney, W.E., Jr. The effect of pimozide on CSF norepinephrine in schizophrenia. American Journal cf P.cyhiarr,~,
138, 1045 (1981).
Ziegler. M.G.. Lake, C.R., Wood, J.H.. Brooks, B. R., and Ebert. M. H. Relationship between norepinephrine in blood and cerebrospinal fluid in the presence of a blood-cerebrospinal fluid barrier for norepinephrine. Journal qf‘ Neurochemistrjs, 28,677 (1977).
250 Addendum After the submission of this article, D. Kemali, M. Del Vecchio, and M. Maj (Biological Ps?~chiatry, 17, 7 I I, 1982) reported increased NA levels in the CSF of 8 schizophrenics who had been drug free for 15 days as compared to IO healthy controls. No significant differences were found in the CSF DA concentrations between patients and controls. We are presently investigating the NA and DA concentrations in the CSF of schizophrenics before and after 3 weeks of treatment with haloperidol (mean 25 mgiday). The preliminary evaluation of the first nine patients showed that NA increased significantly in sellen patients after 3 weeks on neuroleptics, but no consistent trend could be observed for the DA concentrations in this small sample.