Psychiatric Syndromes

Transcription

1 Psychiatric Syndromes THE RELATIONSHIP BETWEEN ABO BLOOD GROUPS AND SCHIZOPHRENIA A Report ofnegative Findings* GEORGE PETERFY, M.D.! LESLIE SOLYOM, M.D. 2 ALAN G. KENDALL, M.D.3 MAJA TURCAN, B.A. 4 Introduction Since Aird et ai.(l) published their findings on the relationship between blood group A and cancer of the stomach in 1953 and between blood group 0 and peptic ulceration (2) in 1954, subsequent research has provided many controversial results concerning the relationship between blood groups and various diseases. In 1959, Helmbold (11) suggested that this association could probably be explained by immunological processes. Vogel (18) in 1970 concluded that, "... associations between ABO blood groups and disease have been established beyond any reasonable doubt. They seem to influence fitness in higher age groups under modern living conditions. Under primitive conditions, the relationship of the ABO blood groups with resistance to infectious diseases, and hence an influence on natural selection, is very likely." At the same time, Talbot et al. (16) found that people with blood group o were thought to be less liable to venous thromboembolism than those of the remainmg groups. Recent work on antigens common to human and bacterial cells appears to throw some light on how the above mentioned clinical findings might be explained. Drach, *Manuscript received October 'Senior Psychiatrist, Associate Director of Clinical Research, Allan Memorial Institute, Montreal, Quebec. 'Senior Psychiatrist, Allan Memorial Institute. 'Director Transfusion Service, Royal Victoria Hospital, Montreal. 'Research Assistant, Allan Memorial Institute. Can. Psychiatr. Assoc. J. Vol. 21 (1976) Reed and Williams (6) suggested that "... cumulatively, genetic ability to produce antibody to both A-like and B-like antigens would seem most protective." In an earlier work (5) they also suggested that "Group A, B, and AB persons would be partially or completely unable to recognize A- or B activity as antigenic, thereby predisposing them to infection. " It is assumed that in certain emotional diseases, enzymatic processes dependent on the genotype, such as MAO activity, are potentially important. In the field of psychiatry, however, the relative contribution of genetic versus environmental factors to the etiology of psychiatric illness remains largely unknown and still debated by the psychiatric schools. Although some early work on the association of ABO blood groups with mental disorders was done by Thomas and Hewitt (17) in 1939, and later by Lafferty, Knox, and Malone (13), their description of schizophrenia and the lack of adequate methodological detail rendered their results doubtful. The first scientifically valid study was done by Masters (14) in After warning against psychiatry's over-eager acceptance of the usual 5 percent and I percent levels of significance, he found that there was a suggestion of an increased incidence of group 0 in manic-depressive psychosis, but no significant correlation between ABO blood groups and any other psychiatric illness. He also suggested that, despite the apparent associations between blood group and disease, direct causal effect 303

2 304 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 21, No.5 is unlikely and that pleiotropism - a single gene controls more than one character (9) could explain the association of certain illnesses with a particularblood group. In schizophrenia the question of an association with a particular blood group remains unresolved. In an experimentally well-designed study, Andersen and Ekstrom (3) concluded that there was no distribution difference for the various blood groups among schizophrenics and the normal population - a finding that has been corroborated by other more recent studies (7, 8, 10). However, other investigators have found that there is an under-representation of blood group 0 and an over-representation of blood group A among schizophrenics (4, 12, 15). The contradictory results may be due, among other variables, to the insufficient evidence for diagnosing schizophrenia and to the lack of homogeneity in the patient population. To remedy the situation, our study rigorously defined schizophrenia and strived to select a more homogenous control population. Method The schizophrenic population was chosen over a period of one year from among patients who regularly attended the schizophrenic follow-up clinic at the Allan Memorial Institute. Blood samples were drawn from each patient and both forward and reverse ABO blood grouping was carried out by the Royal Victoria Hospital Blood Transfusion Service, employing standard procedures recommended by the American Association of Blood Banks. The diagnosis of schizophrenia was accepted only for those patients whose symptoms were characteristic of schizophrenia according to the criteria of either E. Bleuler or K. Schneider. However, one symptom without the typical constellation of other schizophrenic symptoms or typical course of schizophrenia did not meet criteria, and such patients were excluded from the study. Table I lists the criteria of Bleuler and Schneider. The control population consisted of nonpsychiatric patients admitted to the Royal Victoria Hospital during the same time period and who had had their blood typed for various medical reasons by the Hospital's Blood Transfusion Service. The blood type distribution of this population stabilized after four thousand cases had been tabulated. It is assumed that this number of control subjects adequately reflects the blood type distribution of the Hospital's catchment area from where the schizophrenic population was also drawn and that the ethnic distribution of the two groups is similar. Results The experimental population consisted of 137 patients, of whom 28 did not conform to our criteria and were omitted. In addition, another group of seven schizophrenic patients were omitted because their diagnosis also included alcoholism, post partum psychosis, organic brain syndrome, and so on. The final sample consisted of 102 TABLE I CRITERIA OF SCHIZOPHRENIA OF E. BLEULER AND K. SCHNEIDER Bleuler Symptoms Primary Flatness of affect Loosening of associations Autism Secondary Delusions Hallucinations Others Schneider Symptoms First rank Hears voices speaking his thoughts. Voices heard arguing or discussing him. Voices heard describing his activity. Delusional percept - normal perception followed by highly personalized delusional interpretation. Somatic passivity Thought insertion Thought withdrawal Thought broadcasting Made feelings Made impulses Made volition Others

3 August, 1976 Characteristics ABO BLOOD GROUPS AND SCHIZOPHRENIA TABLE II CHARACTERISTICS OFSCHIZOPHRENIC SAMPLE POPULATION Male Female N = 52 N = Age Mean. Range. Duration ofillness Mean. Range. In social remission Course ofillness Intermittent. Improving. Stable. Acute. Deteriorating. No information yrs 44.3 yrs " " 11.6yrs 13.0 yrs 0-37 " cases 37 cases 13 " 7 " 2 " 2 " I " 2 " 0 " I " 0 " I " patients (52 males and 50 females) with a mean age of 40.9 years, ranging from 20 to 65 years. Table II provides some descriptive variables for this experimental group. Most TABLE III DISTRIBUTION ACCORDING TOBLEULER AND SCHNEIDER CRITERIA Criteria Male Female Total According to Bleuler According to Schneider patients were chronically ill, but at the time of study, the majority were in social remission - functioning outside the hospital. Table III gives the incidence of the Bleulerian and Schneiderian symptoms manifested in the schizophrenic group. Without exception, all subjects had at least one of the Bleulerian symptoms and a little more than half had the first rank symptoms of Schneider. There was, of course, considerable overlap between the two types of criteria. Table IV shows the distribution of blood groups among the schizophrenic and control populations, and includes the blood type TABLE IV ABO BLOOD GROUP DISTRIBUTIONS AMI Patients RVH Patients Strictly Schizophrenic, Schizophrenic Not Control Schizophrenic including symptoms, plus Schizophrenic Population additional alcoholism, diagnosis drugs,organi- Blood city, etc. Group N = 101* N = 108* N =7 N =21 N = 4000 A % % I % % B % % % % AB 6 5.9% 7 6.5% 0 I 4.8% % % % % % 'One patient did not have her blood group determined.

4 306 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 21, No.5 distribution for the excluded patients. The differences in blood type distribution for the experimental and control groups did not reach statistical significance (X 2 = 4.02, df = 3, 0.2>p>0.1). Discussion The results indicate no correlation between blood group and schizophrenia. This finding is concordant with the results of the four studies already mentioned, three of which also utilized non-psychiatric hospital populations as control subjects. In one of these studies, Elston et al, (8) investigated 89 patients with varying types of psychosis, and in particular schizophrenia, with the same sex dizygotic twin. Despite having minimized the effect of many other variables, including ethnicity, dissimilarities in upbringing, and so on, they also found no significant association between schizophrenia and blood group. In the three studies mentioned earlier, which suggest a correlation between blood group and schizophrenia, the A (or Ai) blood type was found in a higher proportion among schizophrenics than among the control population. From a perusal of the literature it seems that the most frequent methodological weakness, common to all studies, is that the diagnosis of schizophrenia was based on the retrospective scanning of case histories written by psychiatrists or psychiatric residents of differing levels ofsophistication and diagnostic habits. What should be considered schizophrenia is still under investigation (19) and as long as the nosology remains controversial, diagnostic practices will reflect instability of classification from hospital to hospital, not to mention from country to country. Establishing an unequivocal relationship or no relationship between blood group and schizophrenia must wait until schizophrenia can be diagnosed with the same certainty as the blood group to which it mayor may not be associated. Summary It is less than a decade since the first scientifically valid study of a possible link between blood groups and schizophrenia was published. The results of the few articles which have appeared since then are contradictory and do not clarify the original problem. This might be due to insufficient evidence for diagnosing schizophrenia and to a lack of homogeneity in the patient population. To remedy this situation in the present study only those patients whose symptoms were characteristic of schizophrenia according to the criteria of either E. Bleuler or K. Schneider were accepted. Our results indicate no correlation between blood group and schizophrenia. Until schizophrenia can be diagnosed with the same certainty as can ABO blood groups, the relationship between them cannot be scientificallyestablished. References I. Aird, 1., Betall, H. H., Roberts, 1. A. F.: A relationship between cancer of the stomach and ABO blood groups. Br. Med. J., 1: I, Aird, 1., Betall, H. H., Mehigan, 1. A., Roberts, J. A. F.: The blood groups in relation to peptic ulceration and carcinoma of colon, rectum, and bronchus; an association between the ABO groups and peptic ulceration. Br. Med. J., 2: , Andersen, E., Ekstrom Larsen, K.: Schizophrenia and blood groups (Schizofreni og blodtyper). Nord. Psychiat. Med., 13: , 1959 (in Danish). 4. Czechowicz, A. S., Pamnany, L.: ABO blood types and the aetiology of schizophrenia.med. J. Aust., 1: , Drach, G. W., Reed, W. P., Williams, R. C. Jr.: Antigens common to human and bacterial cells: Urinary tract pathogens. J. Lab. Clin, Med., 78: , Drach, G. W., Reed, W. P., Williams, R. C. Jr.: Antigens common to human and bacterial cells: lie. Coli 014, the common enterobacteriaceae antigen, blood groups A and B, and E. Coli 086 J. Lab. Clin. Med., 79: 38-46, Dutta, R. N., Jetley, S.K.: Schizophrenia: Its relationship with ABO and Rhesus blood groups, and with secretor/non-secretor status of ABH blood group specific substance. 1ndian Psychiatry (Chandigarh) 15: , Elston, R. C., Kringlen, E., Namboodiri, K. K.: Possible linkage relationships between certain blood groups and schizophrenia or other psychoses. Behav. Genet., 3: , 1973.

5 August, 1976 ABO BLOOD GROUPS AND SCHIZOPHRENIA Evans, D. A. P.: Confirmation of association between ABO blood groups and salivary ABH secretor phenotypes and electrophoretic patterns of serum alkaline phosphatase. J. Med.Genet.,2: , Gaekwad, R. S., Niyogi, A. K., Jagtiani, R.: ABO blood group genes in schizophrenia and manic depressive psychosis. Indian J. Med. Sci., 26: ,1972. II. Helmbold, W.: Uber den Zusammenhang zwischen ABO-Blutgruppen und Krankenheiten: Betrachtungen zur Ursache der ABO-Frequenzvershiebung bei Patienten mit Carcinoma ventriculi, Carcinoma genitalis und Ulcus ventriculi. Blut, 5: 7-22, Irvine, D. G., Miyashita, H.: Blood types in relation to depression and schizophrenia. Can. Med. Assoc. J., 92: , Lafferty, C. R., Knox, W. J., Malone, M. C.: Schizophrenia in relation to blood groups ABO and blood types RhD and MN. Am. J. Psychiatry 113: 1117, Masters, A. B.: The distribution of blood groups in psychiatric illness. Br. J. Psychiatry 113: , Medlewicz, J. Massart-Guiot, T., Wilmotte, J., Fleiss, 1. L.: Blood groups in manicdepressive illness and schizophrenia. Dis. Nerv. Syst, 35: 39-41, Talbot, S., Wakley, E. J., Ryrie, D., Langman, M. J. S.: ABO blood groups and venous thromboembolic disease. Lancet, 1: , Thomas, J. c., Hewitt, E. J. c.. Blood groups in health and in mental disease. J. Ment. Sci., 85: , Vogel, F.: ABO blood groups and disease. Am. J. Hum. Genet., 22: , Yusin, A., Nihira, K., Mortashed, c.: Major and minor criteria in schizophrenia. Am. J. Psychiatry 131: , Resume II y a moins de dix ans que la premiere etude vaiable au point de vue scientifique, sur la possibilite d'un rapport entre les maladies mentales et les groupes sanguins a ete publiee. Les conclusions des quelques articles parus depuis n'eclairent en rien Ie probleme original, vu que ceux qui ayant trouve une correlation certaine entre groupe sanguin et schizophrenic et ceux qui n' en purent trouver aucune, se chiffrent en proportions egales. Notre opinion etait que ces resultats contradictoires etaient peut-etre dfis al'insuffisance des elements permettant Ie diagnostic de la schizophrenic et au manque d'homogeneite de l'ensemble des patients. Afin de corriger cette situation, nous n'avons accepte que les patients dont les symptornes etaient caracteristiques de la schizophrenic selon les criteres de E. Bleuler ou de K. Schneider. La population schizophrene fut choisie au cours d'une periode d'un an parmi les patients suivis par la Clinique de Schizophrenic de l'institut Allan Memorial. Du groupe experimental de 137 patients, seulement 102 repondaient aux criteres ci-haut mentionnes, Le groupe controle se composait de patients admis aux sections non psychiatriques de l'hopital au cours de la merne periode. Nos resultats n'indiquent aucune correlation entre Ie groupe sanguin et la schizophrenie. Nous sommes d'opinion que, aussi longtemps que la schizophrenic ne pourra etre diagnostiquee avec la meme certitude que les groupes sanguins A, B et 0, on ne pourra etablir de facon scientifique les rapports qui existent entre eux. [The science oflife] is a superb and dazzlingly lighted hall which may be reached only by passing through a long and ghastly kitchen. An Introduction to the Study ofexperimental Medicine Claude Bernard