Question: What is the cause of her psychiatric problems according to

Genes and environment:
The complex etiology of psychiatric
János Réthelyi, M.D., Ph.D.
Department of Psychiatry and Psychotherapy
Semmelweis University
September 18th 2013
• The issue of Gene-Environment Interactions: Why
are they important?
• Methods in psychiatric genetics
• Psychiatry in a nutshell: Dementia, Schizophrenia,
Depression, Bipolar Disorder, Personality
• Implementation of genetic results:
Pharmacogenetics, drug development, prevention.
Case presentation
• 23 year old female patient presents herself at the
Department after a family debate.
• Chief complaints: „I am treated brutally by my
family… I think people on the street mean bad to
• Following examination: symptoms of anxiety,
paranoid and religious delusions, acoustic
hallucinations (I heard the voice of Jesus.)
Question: What is the cause of her psychiatric
problems according to the patient? According
to you?
How do we call the decribed condition?
What is the most probable diagnosis?
What other diagnoses should we think of?
What is the cause of her psychiatric problems
according to the patient?
• According to you?
• The fundamental question of etiology: What
causes the disorder? Environmental or genetic
Psychiatric disorders
Mental disorders: significant dysfunction in an
individual’s cognitions, emotions, or behaviors
Diagnoses based on behavioral assessment, no lab
tests or biomarkers are available (except for organic
Why do we think that they have anything to do with
Heritability of psychiatric disorders
ASD: autism spectrum disorders
AD: Alzheimer dementia
ADHD: attention-deficit hyperactivity disorder
AN: anorexia nervosa
ALC: alcohol dependence
BIP: bipolar disorder
BRCA: breast cancer
CD: Crohn disorder
MDD: major depressive disorder
NIC: nicotine dependence
SCZ: schizophrenia
T2DM: type 2 diabetes mellitus
From: Sullivan et al, 2012. Genetic architectures of psychiatric disorders: the emerging picture and
implications. Nature
Genetic studies
Population genetics:
Molecular methods
Family studies
Linkage studies
Twin studies
Association studies
Adoption studies
Expression studies
(epigenetic analyses)
Epidemiologic studies:
Genetic cohorts
Animal models
A typical genetic analysis workflow
Population studies
Molecular methods
Candidate genes
Epidemiologic analyses
biological hypotheses
Genetic Risk
Results of Psychiatric GWAS Studies
…the interpretation
Main symptoms: delusions, hallucinations,
disorganized thoughts and behavior
Familial transmission is straightforward (heritability:
0.8, MZ twins: 48-59%, DZ twins: 16% concordance)
Referred to as the totally unsuccessful example of
linkage and association studies
GWAS studies did not replicate previously implicated
candidate genes, and significant markers only
explain 3% of the heritability -> “missing heritability”
Candidate genes in schizophrenia
Which character suffers from schizophrenia in
one of Shakespeare’s dramas?
John William Waterhouse:
Edgar - Tom O’Bedlam
(King Lear)
Alzheimer dementia
Main symptoms: Progressive deterioration of
cognitive abilities, agitation, hallucinations.
Neurodegenerative disease, EC: neuritic plaque, IC:
neurofibrillar filaments, beta-amiloyd
Familial AD (5%): mendelian transmission, dominant,
early manifestation: APP (amyloid precursor protein),
presenilin1, presenilin 2
Sporadic AD (95%): polygenic, late-onset:
apolipoprotein E e4 allele risk factor, GWAS
APP gene on chromosome 21- association with
Mood disorders
Depression: depressed mood,
performance problems, somatic
symptoms (loss of appetite,
sleep problems)
Mania: elevated mood,
hyperactivity, decreased critical
Bipolar disorder: cycles of
depression and mania, social
disability, family problems, high
suicide risk
DEPRESSION: abnormal sadness, loss of joy and motivation, decreased
energy, desperation, and suicide
Van Gogh
Genetics of mood disorders
Highly prevalent disorders (MDD~15%, BD~6%)
Familial transmission straightforward in BD (h2: 0.8, MZ:
65%, DZ: 14%), moderate in MDD (h2: 0.39, MZ:50%,
GWAS studies yielded a few significant markers in BD
with only 1 gene in concert with linkage results
(CACNA1C, OR=1.14), again explaining only 2% of
heritability variance
No markers reached significance in MDD, and the main
candidate gene (SLC6A4) association was dismissed by
recent meta-analyses
What is the explanation? Why can’t we find the genes for
schizophrenia, dementia, or depression?
 Although psychiatric disorders have a high heitability
we couldn’t identify individual genes or polygenic
 Gene-gene interactions? Epistatic and other
regulatory mechanisms?
 Is there any other factor that we should consider?
Gene-Environment Interactions
Refers to the phenomenon where genetic and
environmental factors both play a role in the etiology
of a disease and possibly strengthen each others
Especially important in chronic non-communicable
diseases and psychiatry.
Elucidating GxE interactions can lead to better
prevention and therapeutic measures.
The field is connected closely to psychiatric
Caspi és Moffitt, 2006.
Gene-Environment Interactions
Synergistic: G and E factors enhancing each
others’ effect
Antagonistic: G and E suppress each other
Vulnerability model: G predispose a sensitivity
towards E stressors
Plasticity model: G may confer susceptibility,
but can be beneficial in optimal E
Gene-Environment Interactions
From: van Os et al., 2010. The environment and schizophrenia. Nature
Environmental risk factors in schizophrenia
From: Sullivan, 2005. The Genetics of Schizophrenia. PloS Medicine
Environmental risk factors in schizophrenia
The influence of adolescent-onset cannabis use on adult
psychosis is moderated by variations in the COMT gene
Caspi et al, 2005.
13% of individuals carrying the Val/Val genotype
and using cannabis had schizophreniform
Good idea to genotype yourself before you fly
to Amsterdam.
GxE effect on psychotic outcomes
Serotonin transporter (SLC6A4, 5-HTT)
Lesch et al, 1998
Location: 17q11.2
Major regulatory element in the serotonin transmission and primary target of
antidepressant (SSRI) medications
S allele (14 repeats) -> reduced expression level and slower serotonin turnover
L allele (16 repeats) -> normal expression level and serotonin turnover
Influence of Life Stress on Depression:
Moderation by 5-HTTLPR
From: Caspi et al, 2003. Science
Influence of 5-HTTLPR on Depression:
Moderation by Environmental Risk
From: Belsky et al., 2009. Vulnerability genes or plasticity genes? Molecular Psychiatry
Influence of 5-HTTLPR on Stress-Reactivity:
Moderation by Environmental Risk
From: Muller et al, 2011. Interaction of Serotonin Transporter Gene-Linked Polymorphic Region
and Stressful Life Events Predicts Cortisol Stress Response. Neuropsychopharmacology
Sounds good so far, but…
Reanalysis of the original data, and new data from the
30 year follow-up study (Dunedin cohort)(Fergusson
et al, 2012, Munafò et al., 2009, Risch et al, 2009)
don’t support the original interaction between 5HTTLPR and stressful life events.
The interface of GXE: The epigenome
 Epigenome: Charactreistics of the genome that are
not related to the DNA-sequence (DNA methylation
pattern, histon acethylation or methylation, chromatin
 Many changes in early phases of development
(malnutrition, parebtal neglect, abuse)
 Tissue-specific
 Epigenetic changes can be inherited up to 3
Epigenetics findings
 Methylation status of BDNF promoter is associated with
MDD in a Japanese sample (Fuchikami et al, 2011).
 Voluntary exercise in mice induces demethylation in
neurons (Pinilla-Gomez, 2012)
 Intense exercise and IL-1ß, TNF-α change in humans
predicts remission of patients with depression (Rethorst et
al., 2012)
Critics of the scientific
community: Current results don’t
support the use of genetical
testing for diagnostic purposes.
Ethical problems!
GxE and Therapy
Therapy itself is an environmental factor, introducing
epigenetic modifications
Pharmacogenetic variations are important in
predicting treatment response (eg. COMT
Val158Met, CYP2D6, CYP3A4, HTR2A
polymorphisms on response to clozapin)
CYP2D6, CYP2C19 poor or ultrarapid metabolizers
need personalized dosage of psychotrop meds
From: JC Stingl et al., Genetic variability of drug-metabolizing enzymes: the dual impact
on psychiatric therapy and regulation of brain function. Mol Psych (2012), 1-15
Changes in activity of amygdala, prefrontal cortex
and hippocampus in depressed patients after
successful psychodynamic psychotherapy
Buchheim et al., 2012
Differences in D2 receptor binding after successful
cognitive-behavior therapy in patients with social
From: Cervenka S. et al, 2012
Take-home messages
Genetic and environmental factors are both
extremely important in the etiology of psychiatric
Schizophrenia: high heritability, demonstrated geneenvironment interactions for urban upbringing and
cannabis use.
Major depression: moderate level of heritability,
demonstrated interactions between HTTLPR and
stressful life events
Understanding gene-environment interactions is very
important for the treatment as well
Thank you for your attention!
[email protected]

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