Genomic and Proteomic markers in Forensic Psychiatry

Adonis Sfera, MDWith input from Mario Mendez MD, PhD

Outline

Genomic markers for fragile X syndrome Molloy v Meier - genomic markers in the

courtroom Neuro-moral network Myths and facts about genes Proteins – the building blocks of life

Levels of brain organization

Neurobiology can be studied at two levels of organization:

-cellular (cell-cell or cell-ECM interactions) -molecular (molecular networks enmesh the entire CNS)

From cellular to molecular level mid 1980sProtein mass spectrometryConfocal laser scanning microscopeMultiphoton microscope

Cellular biomarkers

Cellular connectomics (neuroimaging and electrophysiology).*Human Connectome Project*Brain cells are organized in networks: neuronal, glial, neuronal-glial and complex cellular networks.

Molecular biomarkers-Genomic markers-Proteomic markers

2003- the holy grail of genetics

Gene mining “gold rush”

Genes – more questions than answers

From the sovereignty of genes to the sovereignty of proteins

Origami – the art of folding

Misfolded proteins: neurodevelopmental and neurodegenerative diseases

HUNTINGTIN PROTEIN = Huntington’s

ALPHA-SYNNUCLEIN = Lewy body dementia, Parkinson’s

TAU = frontotemporal dementia

AMYLOID BETA PROTEIN = Alzheimer’s

PRION PROTEIN = Creutzfeld-Jacob

DISC 1 PROTEIN = Schizophrenia

Fragile X syndrome-molecular level

FMR1 gene fragile X mental retardation 1 protein (FMRP)

CGG triplet repeat, is expanded in the FMR1 gene

misfolded FMRP

Fragile X syndrome- cellular level

Genetic markers in the courtroom

Some neurodevelopmental and neuropsychiatric conditions such as Fragile X syndrome, velo-cardio-facial syndrome or Huntington’s disease biological markers are accepted in court.

Molloy v Meier-genomic markers and duty to warn Dr. Meier, a pediatrician, treated Mrs. Molloy's minor daughter for developmental delays.

Mrs. Molloy informed Dr. Meier that her half brother was mentally retarded.

Dr. Meier ordered chromosome testing on Mrs. Molloy's minor child.

She did not, however, recommend testing for Mrs. Molloy. Nor did the testing that she ordered specifically test for Fragile X syndrome. The results of the chromosome tests were negative.

Later, Mrs. Molloy gave birth to another child, who was similarly disabled as the sister.

Mrs. Molloy and the two children then underwent genetic testing, which identified all of them as carriers of the genetic mutation associated with Fragile X syndrome.

Mrs. Molloy sued Dr. Meier, alleging that she failed to properly order and interpret genetic testing, and that she failed to provide adequate genetic counseling to the parents.

The lawsuit further alleged that the parents would not have conceived another child had they known that their first child had Fragile X syndrome, and that the mother was a carrier.

The Minnesota Supreme Court ruled that "a physician's duty regarding genetic testing and diagnosis extends beyond the patient to biological relatives who foreseeably may be harmed by a breach of that duty."

Talking about genomic markers…

The neurobiology of morality

The neurobiology of moral behavior

Humans have an innate moral sense based in a neuromoral network centered in the ventromedial prefrontal cortex and its connections including anterior insula (AI) and anterior cingulate cortex (ACC).

The neuromoral network works through moral emotions and moral drives, such as the avoidance of harm to others and the need for fairness and punishment of violators.

Disorders of this region, such as focal lesions or frontotemporal dementia, disturb personal, intrinsic moral emotions and decision-making.

Clinicians must recognize and manage “acquired sociopathy” and other dysmoral behaviors associated with disorders of the neuromoral network.

Patients with these disorders pose a special problem for forensic neuropsychiatry.

Mario F. Mendez, MD, PhD. The Neurobiology of Moral Behavior: Review and Neuropsychiatric Implications. CNS Spectr. 2009 November; 14(11): 608–620. PMCID: PMC3163302 NIHMSID: NIHMS296407

A universal normative morality

Philosophers since pre-Socratic times have long pondered the existence of a universal normative morality in addition to the descriptive codes proposed by each society,

religion, or legal system.

The neuro-moral network in higher mammals

.Studies with apes and other social animals describe moral emotions:

-empathy-gratitude-a sense of fairness-emotional reciprocation-consolation-group loyalty.

De Waal FB. How animals do business. Sci Am. 2005;292:54-61.

Haidt J. The emotional dog and its rational tail: A social intuitionist approach to moral judgment. Psychol Rev. 2001;108:814-834.

Where is the moral brain? A neuro-moral neuronal network was

described consisting of right VMPFC and its connections to ACC and INS.

Mario F. Mendez, MD, PhD. The Neurobiology of Moral Behavior: Review and Neuropsychiatric Implications. CNS Spectr. 2009 November; 14(11): 608–620. PMCID: PMC3163302 NIHMSID: NIHMS296407

Von Economo Neurons (VEN) The cells of empathy?

*Human: 82,855 *Gorilla: 16,710, *Chimpanzee: 1,808

Found in anterior insular cortex (AI) and anterior cingulate cortex (ACC)

Where in the world is insula?

Anterior Cingulate Cortex (ACC)

Santillo AF, Mårtensson J, Lindberg O, Nilsson M, et al. (2013) Diffusion Tensor Tractography versus Volumetric Imaging in the Diagnosis of Behavioral Variant Frontotemporal Dementia. PLoS ONE 8(7): e66932. doi:10.1371/journal.pone.0066932http://www.plosone.org/article/info:doi/10.1371/journal.pone.0066932

The salience network of the brain

Empathy and compassion The neuro-moral network processes: -moral emotions -moral drives-avoidance of harm to others -the need for fairness -punishment of violators.

Disorders of the neuro-moral network

Focal lesions or frontotemporal dementia (FTD), disturb personal, intrinsic moral emotions and decision making

Sociopathy Functional neuroimaging studies demonstrate

frontotemporal hypometabolism, hypoperfusion, or changes in spectroscopy in murderers pleading not guilty by reason of insanity and in violent psychiatric inpatients.

A reduction in prefrontal gray matter volume associated with reduced autonomic arousal in violent offenders.

The smaller the volume of prefrontal cortex, the greater the tendency towards sociopathic behavior in sociopaths.

Sapolsky RM. The frontal cortex and the criminal justice system. Philos Trans R Soc Lond B Biol Sci. 2004;359:1787-1796.Veit R, Flor H, Erb M, et al. Brain circuits involved in emotional learning in antisocial behavior and social phobia in humans. Neurosci Lett. 2002;328:233-236.

Developmental and acquired sociopathy

.Sociopathy Antisocial personality disorder

Developmental sociopathy-lack moral emotions, empathy, conscience, or remorse and guilt for their acts

-normal moral knowledge and reasoning.

-instrumental (cold-blooded and goal-directed) aggression with decreased sympathetic arousal.

-minimal alterations in heart rate, skin conductance, or respirations when they are subjected to fear, stressful or unpleasant pictures,

-reduced autonomic responses to the distress of others, as well as reduced recognition of sad and fearful expressions.

Tiihonen J, Rossi R, Laakso MP, et al. Brain anatomy of persistent violent offenders: more rather than less. Psychiatry Res. 2008;163:201-212.

Genomic markers of developmental sociopathy

DRD2 contains two alleles A1 and A2. A1 allele is associated with involvement in acts of serious physical violence and aggression.

DRD4 located on chromosome 11 has a polymorphism in the 3rd exon consisting of 7-repeat allele associated with extreme violence and aggression.

5HTTLPR located on chromosome 17 has a polymorphism that contains low and high expressing alleles. The low expressing allele was associated with antisocial personality disorder.

COMPT located on chromosome 22, has a polymorphism consisting of a single nucleotide difference (methionine replaced by valine). Carriers of met allele display signs of violence and aggression including antisocial personality disorder.

MAOA has two polymorphisms low and high activity alleles. The low activity allele is associated with violence and aggression.

Christopher J Ferguson, Kevin M Beaver. Natural Born Killers: The Genetic Origins of Extreme Violence . Aggression and Violent Behavior Volume:14 Issue:5. September/October 2009 Pages:286 to 294

Phineas Gage: aquired sociopathy

Connectomics and Phineas Gage

Frontotemporal dementia behavioral variant (bvFTD)

The second most common dementia Young onset (midlife) Behavioral changes usually misdiagnosed as

psychiatric d/o 20-50% of cases are hereditary 15% autosomal dominant TAU protein misfolded, but not amyloid beta protein VENs are specifically and selectively attacked

(reduced by an average of 74%)

John M. Allman, Nicole A. Tetreault, Atiya Y. Hakeem, Kebreten F. Manaye, Katerina Semendeferi, Joseph M. Erwin, Soyoung Park, Virginie Goubert, and Patrick R. Hof. The von Economo neurons in the frontoinsular and anterior cingulate cortex. ANNALS OF THE NEW YORK ACADEMY OF SCIENCES, ISSN 0077-8923

FTD: acquired sociopathy

transgression of social norms including sociopathic behavior

loss of empathy or appreciation of the

feelings of others, disinhibited, compulsive acts

often commit criminal violations while retaining the ability to know moral rules and conventions.

Mario Mendez. The Unique Predisposition to Criminal Violations in Frontotemporal Dementia. J Am Acad Psychiatry Law. 2010; 38(3): 318–323. PMCID: PMC31395

Signs and symptoms of bvFTD

Unsolicited sexual approach or touch

Traffic violations including “hit-and-run accidents

Physical assaults

Shoplifting

Deliberate non-payment of bills

Pedophilia

Indecent exposure in public

Urination in inappropriate public places

Stealing food

Eating food in grocery stores stalls

Breaking and entering into other’s homes

Mario Mendez. The Unique Predisposition to Criminal Violations in Frontotemporal Dementia. J Am Acad Psychiatry Law. 2010; 38(3): 318–323. PMCID: PMC31395

Insula degeneration in bvFTD Insular atrophy is one of the earliest structural

biomarkers in behavioral variant FTD (bvFTD)

Insular VEN degeneration in bvFTD

A cluster of dysmorphic right Insula VENs

Why is this important for clinicians?

When patients present with dysmoral behavior for the first time, as a change from a prior pervasive pattern of behavior, clinicians need to consider a possible, causative brain disorder.

Family and friends need education as to the significance of the patient’s behavior, and the question of whether their dysmoral behavior is their “fault” may need frank discussion.

Medications can be useful in controlling related behaviors such as impulsivity, but do not selectively suppress dysmoral behavior.

Selective serotonin reuptake inhibitors, beta-blockers, and mood stabilizing antiepileptic agents (such as valproate, carbamazepine, and lamotrigine) could be of help in this regard.

bvFTD and forensic psychiatry

Patients with FTD with disturbed volition have committed crimes and been arrested.

The US federal insanity defense hardens the original M’Naughton rule, requiring the defendant to prove, by “clear and convincing evidence,” that “at the time of the commission of the acts constituting the offense, the defendant, as a result of a severe mental disease or defect, was unable to appreciate the nature and quality or the wrongfulness of his acts” (18 U.S.C. § 17).

Without the restraint of intuitive moral emotions bvFTD patients may not be able to deter an impulse to act in an unacceptable manner, even as they know right and wrong and understand the nature of their acts.

These considerations demand a reappraisal of the how we view culpability and criminal violations among brain-injured patients.

Markowitsch HJ. Neuroscience and crime. Neurocase. 2008;14:1-6.

Not Guilty by Reason of Brain Damage? Sapolsky (Phil Trans R Soc London B

2004; 359: 1787-1796) suggests that the insanity defense (not knowing right from wrong) should be expanded to consider impaired volition – diminished impulse control.

Genomic markers of bvFTD

GGGGCC hexanucleotide repeat in the C9ORF72 gene in bvFTD and amyotrophic lateral sclerosis (ALS).

microtubule-associated protein tau (MAPT) gene

progranulin gene (GRN).

Tauopathies - misfolded tau protein

Axonal microtubules and tau protein

Remembering the memory – quick reminder

Synapses or microtubules controversy

Synaptic DarwinismWhere are memories stored?

Neurons that fire together wire together. Memory is attached to synapses (plasticity).

Donald Hebb 1949 “The Organization of Behavior”.

Memory nano-machines

Electronic conductanceAccess to logic gates

Quantum memory?

Traditional computing vs. quantum computing (Bit vs. Qubit)

Bit 0 or 1

Qubit0 and 1

Quick reminder of genomics and proteomics

Genes are the blueprints of lifeProteins are the building blocks of life.

The blueprint of life confused with life itself

Myths and facts about genes

BAD NEWS FIRST: genetics we all learned in college is not valid for the conditions we are treating and studying.

GOOD NEWS: forget genes, study proteins

Rare vs. common diseases Rare diseases (mendelian

transmission) --cystic fibrosis, Huntington’s disease, muscular dystrophies, fragile X, etc.

Common diseases (non-mendelian transmission)--diabetes, asthma, obesity, coronary artery disease, most cancers, schizophrenia, bipolar d/o

Myth # 1 We are different because our genes

are different

Fact # 1 Two unrelated human beings share

99.9% of their genomic sequence, and could be considered almost genetically identical.

Variability 0.1%

Myth # 2 All genes in our genome code for

proteins

Fact # 2 -Only 1.1% to1.4% of the genome's

sequences code for proteins. -Human body contains over 100,000

proteins.

Myth # 3 Genes are structural units.

Fact # 3

Genes are functional units. Definition of a gene: A group of nucleotides

that code for one single protein. Genes can contain from 1,000 to more than

1.5 million nucleotides.

Myth # 4

Identical twins always have identical proteins

Hum Mol Genet. 2011 Dec 15;20(24):4786-96. doi: 10.1093/hmg/ddr416. Epub 2011 Sep 9.Disease-associated epigenetic changes in monozygotic twins discordant for schizophrenia and bipolar disorder.Dempster EL, Pidsley R, Schalkwyk LC, Owens S, Georgiades A, Kane F, Kalidindi S, Picchioni M, Kravariti E, Toulopoulou T, Murray RM, Mill J.

Fact # 4 Expression of genes may differ in identical

twins.

Identical twins convergent for schizophrenia 48%

ST6GALNAC1promoter on chromosome 17- different in identical twins discordant for schizophrenia.

Dempster EL, Pidsley R, Schalkwyk LC, Owens S, Georgiades A, Kane F, Kalidindi S, Picchioni M, Kravariti E, Toulopoulou T, Murray RM, Mill J. Disease-associated epigenetic changes in monozygotic twins discordant for schizophrenia and bipolar disorder. Hum Mol Genet. 2011 Dec 15;20(24):4786-96. doi: 10.1093/hmg/ddr416. Epub 2011 Sep 9.

Proteins – conformational dynamics

Humans have 23,000 genes 1.1% to1.4% code for proteins Over 100,000 proteins in human body

Biomarkers: Ethical considerations Genetic variants predisposing to diseases or predicting drug

response may have medico-legal implications (ex, access to genetic data by employers and insurance companies may lead to discrimination of individuals with an unfavorable genetic constitution or who would only tolerate expensive drugs (Koo, 2006)(Vijverberg, 2010).

The Genetic Information Nondiscrimination Act (GINA) was passed into law on 21 May 2008. However, genetic non-discrimination laws only provide the illusion of protection against potential risks of discrimination (Van Hoyweghen, 2008).

A study reviewed the definitions of genetic testing used by 65 organizations and entities throughout North America and Europe, such as genetics professional organizations, insurance companies, pharmaceutical companies, legal firms, and found extreme variability (Sequeiros, 2005).