Dependent Patients

MUTATION SCREENING OF DOPAMINE AND SEROTONIN CANDIDATE GENES IN TOURETTE'S SYNDROME ANI) ALCOHOL DEPENDENT PATIENTS

Miles Thompson

A Thesis submitted in conformity with the requirements for the Degree of Master of Science Graduate Department of Pharmacology University of Toronto

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Miles Thompson, M.Sc. 1 997

Department of Pharmacology

University of Toronoto

PhamacoIogical evidence suggests that both dopamine and serotonin system genes may be involved in the inheritance of Tourette's syndrome (TS) and alcohol dependence. Dopamine transporter antagoniçts used to treat attention deficit-hyperactivity disorder (AD-HD) worsen comorbid with TS, emphasizing possible TS dopamine dysregulation. Serotonergic antidepressants treating obsessive compulsive disorder (OCD) comorbid with TS and dcohol dependence withdrawal aiso implicating serotonin dysregulation in these disorders. Therefore, we conducted a candidate gene study of the dopamine Dl (DRDI), dopamine transporter

(DAT I ) and serotonin transporter (SHTT) genes in these disorders. The DRD 1 gene was found to be non-polymorphic in patient and control groups. Comrnon conserved sequence variants of the DATl gene were identified but were not associated with TS or alcohol dependence. The short promoter 5HTT gene was significantly more cornrnon in the TS group compared with controls (X2~=0.04), suggesting that the SHTT gene may be a susceptibility locus in TS. 1 would like to thank Drs. Bnan O'Dowd and Susan George for the oppomuiity to be part of their research group. 1 thank our collaborators, Drs. George ühl and David Vandenbergh of the

Laboratory of Molecular Neurobiology, NIDA, for their contributions tn my work on the dopamine transporter gene; Dr. Jeanette Holden, Department of Psychiatry, Queens University for help interpreting her candidate gene studies; Dr. James Kennedy and Dr. Glen Sunohara,

Neurogenetics Section, Clarke Institute, for invaluable insight into the correct tools required to smdy the inheritance of complex neuropsychiatrie disorders. 1 thank Mr. Tuan Nguyen, Ms. Mai

Nguyen. Mr. Yang Shen and Mr. Adriano Marchese for their excellent technical advice. Lastly, 1 thank my farnily and friends for encouraging me to pursue graduate studies. PAGE

Abstract i

Acknowledgments ii

Table of Contents iii

List of Tables vii

List of Figures viii

Abbreviations ix

1. INTRC)DUCTIOIY

1.1 Neurotransmitter G protein coupled-receptors and transporters in disease 1

1.2 Clinical definition of TS, associated disorders and alcohol dependence 3

(a) TS and comorbid neuropsychiatrie disorden 3

(b) Alcohol dependent disorder and associated withdrawal symptoms 4

1.3 The pharmacology of TS, associated disorders and alcohol dependence 5

(a) Typical and atypical neuroleptics implicate dopamine pathways in TS 5

(b) SFüs implicate serotonin pathways in TS-OCD and TS-anxiety 6

(d) SRIs implicate serotonergic pathways in alcohol dependence withdrawal 8

(e) Dopamine is implicated in animai models of aicohol consumption 10

1.4 Mode of inheritance of TS, comorbid disorders and alcohol dependence 10

(a) Autosomal dominant mode1 of TS 1 I

iii (b) Polygenic models ofTS, AD-HD, OCD and alcohol dependence

Candidate gene hypothesis of TS, comorbidities and alcohol dependence

The dopamine hypotheses of TS, AD-HD and alcohol dependence

(a) The DATI and DRD 1 genes are candidates for TS

(b) The DATl and DRD 1 genes are candidates for AD-HD

The serotonin hypothesis

(a) The 5HTT gene is a candidate for TS

(b) The SHTT gene is a candidate gene for aicohol dependence

Screening candidate genes for sequence variants

(a) Mutation screening by SSCP analysis

Research objective: to screen candidate genes for sequence variants

(a) Isolate DATl gene sequence variants in TS and alcohol dependence

(b) lsolate DRDI gene sequence variants in TS and alcohol dependence

Research straterrv for candidate gene screenine and association studies

2- * 2.0 Materials

2.1 DNA extraction

2.2 Clinical sarnples

(a) Tourette's syndrome samples (b) Alcohol dependence samples

2.3 PCR amplification of gene fragments subjected to SSCP mutation screening

(a) Amplification of GPR19 gene fragments used to refme SSCP method

(b) Amplification of DRD 1 fragments to be analyzed by SSCP

(d) Genotyping the DATl 3'VNTR by PCR amplification

(e) Genotyping the SHTT polymorphisms by PCR amplification

2.7 SSCP mutation screening of GPR19, DRD1 and the DATl gene

(a) Overview of the SSCP methodology

(b) SSCP protocol adapted for use with Xcell II apparatus (Novex)

2.8 Identification of sequence variants by chah-termination DNA sequencing

2.9 Statistical Methods

39 l3IEmLE

3.1 SSCP mutation screening revealed polymorphic variants of the GPRl9 gene

3.2 SSCP mutation screening of the DRD 1 gene

3 -3 SSCP mutation screening of the DAT 1 gene

3.4 Association study of DATl polymorphisms in TS and alcohol dependence

3.5 Association study of SHTT polymorphisms in TS and alcohol dependence 4. DISCUSSION

4.0 Interpreting candidate gene sequence variants in patient and control groups

(a) Conservation of the DRD 1 gene in TS and alcohol dependence

(b) DATl gene sequence variants in TS and alcohol dependence

4.1 Conclusions TABLE PAGE

1. Oligonucleotides Used in PCR-SSCP Analysis of Human GPR19 gene 37

2. Oligonucleotides Used in PCR-SSCP Analysis of Human DRD 1 gene 38

-i 3. Oligonucleotides Used in PCR-SSCP Analysis of Human DATl 40 gene

4. DAT l allele and genotype fiequencies: %'P values compare population fiequencies

5. SHTT allele and genotype fiequencies: XZ~values compare patient and control fiequencies FIGURE PAGE

1. The principal of PCR-SSCPanalysis 26

2. Optimization of SSCP temperature, running time and voltage to resolve 48 variants

The effect of SSCP ninning temperature on the resolution of sequence variants

Resolution of sequence variants in TM3 of GPRl9 50

Resolution of TM3 variant on 10% gels was inferior to that on 4-20% gels 52

Analysis of a fragment (350 bp) of the Dl receptor gene 54

SSCP anaiysis of DATl exon 2 in three control subjects 56

SSCP anaiysis of DAT1 exon 8 in three control subjects 57

SSCP analysis of DATl exon 9 in three TS subjects 58

SSCP analysis of DAT 1 exon 15 in three control subjects 59

PCR genotyping of the DATl 3'VNTR 6 1

Deletion/insertion SHTT promoter polymorphisrn genotyped on 4% agarose 65

Intron 2 VNTR polymorphism genotyped on 4% agarose 66 - 1.1 Neurotransmitter G protein coupled-receptors and transporters in disease

A number of diseases known to be caused by sequence variants in G protek coupled

receptors (GPCRs) have been described (Zastawny et al, 1997). Mutations causing both

loss and gain of receptor fûnction have been reported. Retinitis pigmentosa, one of the

earliest characterized GPCR pathologies. was found to be due to a gain of function

mutation in the rhodopsin gene (Dryja et al, 1990; Dryja et al, 1995). A loss of fünction

mutation in the rhodopsin receptor gene was recently found to cause a form of stationary

night blindness (Yamamoto et al, 1997). Other GPCR mutations have been identified.

These include a mutation in the V2 vasopressin receptor gene which causes nephrogenic

diabetes insipidus type 1 1 (van den Ouweland et al. 1992) and a mutation in the thyroid

stimulating hormone (TSH) receptor gene which causes hyperthyroidism (Kopp et al,

1995). Most recently, a mutation in the CCRS gene. a coreceptor for the hurnan

immunodeficiency virus (HIV) that is expressed on T helper cells, has been found to confer resistance to HIV infection (Michael et al. 1997). The identification of simian

imrnunodeficiency virus (SIV) G protein-coupled coreceptors (Farzan et al, 1997), GPRl and GPRI 5 (Heiber et al, 1996; Marchese et al, 1994). suggests that future studies of

GPCR genes in disease States may be relevant and fmitfùl.

Despite the rapidity with which the GPCR genes expressed in the central nervous system (CNS) have been cloned (Marchese et al, 1997;O'Dowd, 1993;Seeman and Van

Tol, 1993), no mutations in these genes have yet been discovered to contribute to the inheritance of neuropsychiatrie disorden (Petronis and Kennedy, 1995).

Pharmacogenetic studies have met with some success in identieing dopamine D4 (DRD4) and serotonin 2A (5HT2A) receptor variants that coder different responses to atypical neuroleptic drug treatment (Seeman et al, 1997; Rao et al, 1997). However, the numerous attempts to utilize genetic markers in order to conduct linkage and association studies of these disorders have not succeeded in convincingly associating GPCRs expressed in the CNS with a neuropsychiatric disorder (Petronis and Kennedy, 1995).

In the work presented here, therefore, we set out to screen candidate genes implicated in Tourette's syndrome (TS) and alcohol dependence for sequence variants that might provide new insight into the inheritance of these disorders. The ernphasis of the work was to screen DNA from patients with TS and alcohol dependence for mutations in genes that had not been subjected to mutation screening previously. Therefore, we screened the

GPR19 gene which, while having no known ligand, shows high sequence homology and similar tissue distribution to dopamine system genes including the dopamine DRD2 gene

(O'Dowd et al, 1996). From among the GPCRs, we also screened the DRûl gene for sequence variants in two disorders that may have doparninergic etiologies: TS and alcohol dependence.

We next elected to screen the dopamine transporter (DAT1) gene for sequence variants in Tourette's syndrome (TS) and alcohol dependence. The final cornponent of the work presented was based on the results of a similar mutation screening project which identified a sequence variant in the 5' regulatory region of the serotonin transporter

(SHTT)gene that has been reported to alter 5HTT gene expression in vitro (Heils et al,

1996) 1.2 Clinical definition of TS, associated disorders and alcohol dependence

(a) TS and comorbid neuropsychiatrie disorders

TS is a relatively rare psychiatrie disorder affecting between 0.1 and 0.5 per thousand

people throughout the world. The cluster of symptoms that underlie TS have their onset

between the ages of 2 and 15. The diagnostic critena include recurrent, involuntary, rapid

motor movements with no purpose (tics) that affect multiple muscle groups. Symptoms

may Vary over weeks or months or may be suppressed in the short term but mut be

otherwise unremittinz for at least a year in order to diagnose TS. The disorder is usually

IifeIong.

The tics are the essential feature of TS. Motor tics comrnonly involve the head, tono

and upper limbs. Vocal tics include sounds such as clicks, gmts, yelps, barks, sniffs,

coughs and words. An irresistible urge to utter obscenities, coprolalia, is present in 60%

of cases. Symptoms are exacerbated by stress but disappear during sleep and absorbing

tas ks.

Associated features of TS include echokinesis, irnitating the movements of someone being observed, and palildia, repetition of one's ovm phrases. Obsessive-compulsive or

ritual behaviors rnay also be present. These include obsessive thoughts of doubting, compulsive rituals including complicated rnovements, impulses to touch objects, retrace steps, squat and twirl when walking (Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, 1990).

TS is often diagnosed cornorbid with obsessive compulsive disorder (OCD)

(Rapoport and Inoff-Germain, 1997; Swedo and Leonard, 1996) or attention deficit- hyperactivity disorder (AH-HD) (Castellanos et al. 1997; Schuerholz et al, 1996). Up to

50% of TS patients have been reported to be diagnosed comorbid with OCD. Comorbid

OCD or AD-HD in TS patients presents a challenge to treatment protocols because of the

need to simultaneously treat TS tics and the comorbid OCD or AD-HD. Treatment

modalities for OCD and AD-HD are distinctly different fiom each other and TS treatments (Peterson, 1996). Major depression (Comings and Comings, 1993; Comings,

1994) and substance abuse disorders, such as alcohol dependence (Muller-Vahi et al,

1997; Comings, 1994), have also been diagnosed comorbid with TS. The contrasting pharmacological interventions used to treat TS and associated comorbidities may provide

insight into the neuropathies that may underlie TS (Singer et al. 1993) and aicohol dependence (Tiihonen et al, 1995).

(b) Alcohol dependent disorder and associated withdrawal symptoms

Alcohol dependence involves a pattern of pathologicd alcohol use or impainnents in social or occupational functions due to alcohol use. The disorder is characterized by the need for daily alcohol consumption and an inability to stop dnnking that is associated with the need for markedly increased arnounts of alcohol in order to satisS, alcohol craving (tolerance) (Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, 1990). The consequence of a cessation of alcohol consumption for an alcohol dependent patient is alcohol withdrawal, which involves severe anxiety, depression, ataxia and muscle tremors (Lejoyeax, 1996; Anton, 19%; Diagnostic and statistical manual of mental disorders, Fourth Edition, 1990). 1.3 The pbarmacology of TS, associated disorders and alcohol dependence

The neurotransmitters dopamine and serotonin have both been implicated in the etiology of TS, associated comorbid disorders and alcohol dependence based on pharmacological evidence (Lejoyeux et al, 1996; Anton et al, 1996; George et al, 1995,

Samson et al, 1993; Dyr et al, 1993). Treatment of these disorders is complex but only those aspects salient to understanding the dopaminergic and serotonergic hypotheses of

TS and associated disorders will be reviewed here. However, the range of therapeutic interventions used to treat these disorden provides strong evidence for their dysregulated neurotransmitter etiology (Wolf et al, 1996; CastelIanos et al, 1997; Uhlenhuth et al,

1995; Narango and Bremner, 1 994).

(a) Typical and atypical neuroleptics implicate dopamine pathways in TS

Dopamine pathways are considered to be involved in TS pathology due to the eficacy of typical neuroleptics, such as haloperidol and primozide, in the treatment of the motor and vocal tics that are central to the disease (Peterson, 1996). Typical neuroleptics are dopamine D2 receptor antagonists, although halopendol is reported to have some a,- adrenergic effects, while primozole is reported to have some calcium channel blocking properties. While side-effects often limit the use of haloperidol (Silva et al, 1996), the fact that it remains a treatment of choice for managing TS motor and vocal tics (Silva et al, 1996; Bruun and Budman, 1996; lancu et al, 1995) provides the best clinical rationale for the hyperdopaminergic hypothesis of TS (Wolf et al, 1996). The involvement of serotonin pathways in TS has less pharmacologicai evidence in its support (Peterson, 1996). There is evidence that the atypical neuroleptic risperidone has some eficacy in treating the tic symptoms of TS (Bruun and Budman, 1996).

Atypical neuroleptics, including rispendone and clozapine, antagonize both dopamine and serotonin receptors. Risperidone, a 5HT2 receptor antagonist and a weak dopamine

D2 receptor antagonist (Peterson, 1996; Bruun and Budman, 1W6), relieves the severity of tics for some patients (Bruun and Budman, 1996), however, in 20% of TS patients treated with risperidone, treatment is curtailed due to weight gain and sedating side effects (Peterson, 1996).

Clozapine, the atypical neurolepic which antagonizes both 5HT2A and dopamine D4 receptors (Seeman et al, 1997), has not been shown to effectively treat tics (Caine et al,

1979) even though it is ofien effective in treating schizophrenia (Seeman et al, 1997; Rao et al, 1996; Meltzer, 1995; Van TOI et al, 1992). In fact, exacerbation of tic symptoms have been reported in some TS patients undergoing clozapine treatment (Caine et al,

1979). It is unclear whether the side effects of clozapine in TS result From serotonin or dopamine receptor antagonisrn (Stein et al, 1997; Peterson, 1996). Taken together, there is clinical and pharmacological evidence of a role for hyperserotonergic dysregulation in the motor and vocal tics integral to TS.

(b) SRIs implicate serotonin pathways in TS-OCD and TS-anxiety

OCD comorbid with TS is often treated successfully with the combination of a neuroleptic to control the tics and a serotonin antidepressant to relieve OCD symptoms (Swedo and Leonard, 1994). Serotonin antidepressants al1 act, at least in part, to correct a

hyposerotonergic state that is hypothesized to underlie depression (Ogilvie et al, 1996;

Heils et al, 1996). By extension, the eficacy of serotonergic antidepressants in treating

OCD suggests that a hyposerotonergic state may also underlie OCD (Uhlenhuth et al,

1 995).

Both tricyclic antidepressants (TCAs) and serotonin reuptake inhibitors (SRIs) are

used to treat OCD comorbid with TS (Stein et al, 1997). The tricyclic antidepressant

(TCA) clornipramine (Stein et al, 1997; Peterson, 1996; Iancu et al, 1995), which

sensitizes serotonin receptors and releases norepinephrine in adrenergic pathways, has been reported to be effective in treating OCD (Iancu et a[, 1995). The autonomic side effects of TCA dnigs, however, limit the use of clomipramine treatrnent. Recently, SRI inhibiton such as fluoxetine and fluoxamine (Stein et al, 1997; Peterson, 1996), which antagonize the serotonin transporter, have been reported effective in treating OCD. In order to treat TS-OCD, patients generally require an SRI or TCA for the relief of OCD symptorns and rispendone augmentation for the relief of the motor and vocal tic symptoms of TS.

Treatment of AD-HD commonly involves the use of dopamine psychotropic agents, such as the dopamine transporter antagonist methylphenidate (MP) (Volkow et al, 1996;

Volkow et al, 1995; Geogiou et ai, 1995). AD-HD treatment, however, often complicates the treatrnent of comorbid TS symptoms (Peterson, 1996). TS patients with comorbid AD-HD require two contrasting dopaminergic interventions. Often the sedating

properties of typical neuroleptics are used to treat the tics associated with TS and a

dopamine psychotropic agent, such as MP, is used to treat AD-HD (Castellanos et al,

1997; Hetchman et al, 1993).

The tic symptoms in patients with TS-AD-HD are cornmonly reported to worsen

imrnediately after MP treatment commences (Daniels et al, 1996). However, once the

MP becomes effective in treating the AD-HD symptorns, tic exacerbation tends to disappear. This makes MP the hgof choice for TS-AD-HD. Other dopamine transporter antagonists, such as dextroarnphetamine, result in unabated tic exacerbation in

TS-AD-HD patients (Castellanos et al, 1997). Cocaine, a dopamine transporter antagonist with a very high af3nity for the dopamine transporter by cornparison with MP, results in extreme tic exacerbation (Castellanos et al, 1997). The complex pharmacology of TS-AD-HD treatment suggests that the doparninergic disregulation in TS-AD-HD may involve many aspects of doparninergic neurotransrnission .

(d) SRIs implicate serotonergic pathways in alcohol dependence withdrawai

SRIs are currently indicated not only for the treatment of obsessive compulsive disorder (Peterson, 1996) but also depression (Ogilvie et al, 1996) and anxiety (Lesch et al, 1996). Detoxification following clinical alcohol dependence is ofien associated with alcohol related anxiety and depression (Lejoyeux, 1996; Anton, 1996). The cornmon alcohol dependence comorbidities, including affective disorders, often obscure whether anxiety and depression cause or are caused by the withdrawal associated with alcohol dependence (Anton, 1996). Regardless of their etiology. the symptoms of depression and anxiety associated with detoxification have been reported to be improved when patients are treated with SRIs (Lojoyewc, 1996; Anton, 1996; Oliver et al, 1993). This suggests that a hyposerotonergic state underlies alcohol dependence.

Hurnan dxug trials and animal experiments also suggest that SRis may be effective in reducing aicohol consurnption and implicate serotonin dysregulation in the pathways involved with alcohol craving. A recent clinical trial of SRIs in non-depressed and moderately depressed aicoholics found that alcohol consumption was decreased 1520% in the SRI treatment groups compared to placebo control groups. SRI treatment of alcohol preferring rats has also been show to result in reduced alcohol consurnption.

However, evidence for long term reduction of alcohol consumption by SRIs is currently lacking (Narango and Bremner, 1994).

The fhct that not al1 serotonergic antidepressants are reported to treat alcohol dependence with the effectiveness of SRIs, however, suggests that much is still to be learned about the significance of serotonergic dysregulation in alcohol dependence

(Lejoyeux, 1996). Clinicai trials of other serotonergic drugs. including the 5HT 1A receptor agonist buspirone, the 5HT3 antagonist ondansetron and the 5HT2 antagonist ritanserin, have met with less success than the SRIs in neating alcohol withdrawal or ongoing alcoholism (Narango and Bremner, 1996). Therefore, although SRI drugs may reverse a hyposerotonergic state that is common in alcoholics, the serotonergic pathology that rnay underlie alcohol dependence remains unknown (Lejoyeux, 1996; Oliver et ai,

1993). (e) Dopamine is implicated in animal models of alcohol consumption

Alcohol dependence may also involve aberrant dopamine pathways (Ng et al, 1997;

Noble, 1996; Thiihonen et al, 1995; Rassnick et al, 1992). Treatment of the hi& ethanol preferring CS7 mouse with the dopamine Dl receptor antagonist SKF 82958 or the dopamine D2 antagonist quinpirole results in markedly decreased ethanol consurnption for 24 hours (Ng et al, 1994). The resumption of ethanol consumption by mice treated with these antagonists has been attributed to receptor desensitization (Ng el al, 1994;

George a2 et, 1995). While this animal model has been used to show the involvement of dopaminergic pathways in alcohol consurnption, no neuroleptic treatment is currently used to treat the primary symptoms of alcohol consurnption or withdrawal in human alcohol dependent patients. A hypodopaminergic hypothesis of alcohol dependence has been inferred frorn decreased ethanol consumption in the mouse model following dopamine D 1 and D2 antagonist treatment (George et ai, 1995; Ng et al, 1994).

1.4 Mode of inheritance of TS, comorbid disorders and alcohol dependence

Debate about whether TS and a range of disorders including OCD, AD-HD and alcohol dependence are part of a heritable TS spectnun disorder (Comings and Comings,

1993) remains controversial (Pauls et al. 199 1; Pauls et al, 1988; Pauls et ai, 1986). The spectrum disorder hypothesis suggests that expression of TS genes results in not only the tics charactenstic of TS but a broad range of associated behaviors including OCD, AD-

HD and aicohol dependence. Support for this idea cornes fiom a number of sources.

First, there is an unusually high incidence with which these disorders are diagnosed comorbidly (Castellanos et al, 1997; Stanley. 1 997; Cornings and Comings, 1993).

Second, pharmacological evidence suggests that this group of disorders share at least

some aspects of dopaminergic and serotonergic dysregulation (Petenon 1996). Third,

evidence exists that relatives of an affected individual are likely to be af5ected by the

same or one of the associated disorders at a rate exceeding that found in pedigrees of

nonpsychiatric individuals (Comings and Comings, 1993; Pauls et al. 1991 : Pauls et al,

1988). To date, however, studies that find evidence for a wide spectnim of related

disorders that share genetic liabilities (Comings et al, 1996) have not been replicated.

(a) Autosomal dominant model of TS

Studies of TS in affected pedigrees have resulted in the hypothesis that TS is inherited

as a single autosomal dominant gene that is subject to incomplete penetrance (Wolf ei al.

1996; Pauls et al, 1986; Comings et al. 1986). The single major locus hypothesis

suggests that the intermediate forms of TS. such as mild tic disorders. may result fiom the

inheritance of a single copy of the susceptibility gent (Comings et al. 1986). Thus. one

copy of the TS gene may confer some nsk while two copies may confer greater risk of developing the severe tic disorder that characterizes TS (Comings et al. 1986). However.

the range of tic seventy found in TS patients (Pauls et al. 1996). combined with the fact

that tic severity worsens when one or both parents have a tic disorder (Comings ei al.

1986), suggests that TS may better fit a more complex model of inheritance (Walkup et al, 1996). Models descnbing TS inhentance as semidominant, sernirecessive or as being an example of incomplete dominance have also been proposed (Patel, 1996) (b) Polygenic models of TS, AD-HD, OCD and alcohol dependence

Linkage studies on Tourette's syndrome have recently introduced evidence that tends to exclude the possibility that a single major locus is responsible for the inheritance of TS

(Heutink et al, 1995). Complex segregation analysis suggests that susceptibility for TS is conveyed by a major locus in concert with a multifactonal background, including polygenetic and environmental contributions (Walkup et al, 1996). A revised mode1 proposes that the major locus is responsible for half of the observed phenotypic variation described in the clinical literature of TS (Patel, 1996; Walkup et al, 1996). Models of TS inheritance must be interpreted with caution, however, because none have yet met with wide acceptance. The greatest complication to exarnining disorders such as TS is that its heterogeneity may confound studies of its inheritance (Patel, 1996; Alsobrook and Pauls,

1996; Santengelo et al. 1996; Pauls et al. 199 1).

Similar problems must be accounted for when studying the genetic component of alcohol dependence (George et al, 1993; Cloninger et al, 1985; Devor and Cloninger,

1989). While Type II alcoholics have been proposed to have a greater genetic liability, which may include a hyposerotonergic phenotype (Cloninger et al, 1989; Cloninger,

1987), studies of this phenotype have not yet resulted in the identification of novel candidate genes for alcohol dependence (Gordis, 1997). Studies associating alcohol dependence with the dopamine Dl (DRDI), dopamine D2 (DRDL), dopamine D4

(DRD4) and DATl genes (to name but a few) al1 remain controversial (Comings et al,

1997; Muramatsu et al, 1995; Carlos et al, 1993; Uhl et al, 1992). The inheritance of alcohol dependence, like that of TS (Patel, 1996), is likely to involve complex interaction

between many susceptibility loci and environmentai factors (Cloninger, 1987; Persico et

al, 1993 ; Muramatsu et al, 1995).

1.5 Candidate gene hypothesis of TS, comorbidities and alcohol dependence

Evidence fiom monozygotic twin studies suggests that a complex genetic liability for

TS, TS associated with AD-HD or OCD and alcohol dependence probably exists (Gordis,

1997; Patel, 1996). Because attempts to isolate candidate genes for TS, AD-HD, OCD

and alcohol dependence by linkage analysis have not been successful (Gordis, 1997;

Heutink et al, 1995; Gelemter et ai, I995), Mendelian inheritance of these disorders is

unlikely. However. failure to detect disease loci by linkage analysis does not exclude

polygenic models of the inheritance of TS or alcohol dependence.

In polygenic models, no single gene that contributes to the inheritance of a disorder is

sufficient in itself to cause the disorder phenotype. Each contributing gene, or susceptibility loci (Nothen et al, 1992), may contribute additively (Comings et al, 1996)

to the inheritance of a suficient genetic liability to cause a recognizable phenotype.

Therefore, much of the recent work on the inheritance of TS, AD-HD, OCD and alcohol dependence has abandoned the method of linkage analysis. the standard means of

identiQing candidate genes for a genetic disorder (Nothen et al, 1992; Hodge, 1994), in

favor of association studies (Owens, 1997; Berrettini, 1997; Hodge, 1994; Nothen et al,

I 992). Association studies involve examining primary candidate genes: genes encoding

proteins that are known to be components of a pathway implicated in the pathology of a

disease. In their simplest fom, association studies involve comparing the frequency of a

genetic marker in patient and control groups (Owens, 1997; Hodge, 1994; Nothen et al,

1992). As a result, association studies are based on parametric models. The use of

parametic models to test the difference between patient ailele and genotype frequencies,

however, is correct only if certain assumption are true (Ott, 1 99 1).

Parametic models assume that while parameters cannot be estimated, standard

randorn variables (statistics), such as the X' statistic, can be calculated in order to test whether significant differences exist between patient and control allele and genotype frequency data. The X' statistic, the normaiized sum of squares of the differences between patient and control allele or genotype frequencies, is assumed to fit a x2 distribution (Ott, 1991). The mode1 also assumes that allele and genotype frequencies in patient and control groups are independent of other variables including the ethnic ongin and sex of the members of each group (Hodge, 1994; Nothen et al, 1992). The fact that association studies have often been found to be confounded by variables other than disease (Kennedy et al, 1995; Barr and Kidd, 1993) suggests that the pararnetric models used in association studies may not always be appropriate.

Linkage analysis, on the other hand, is a non-pararneuic approach that does not require data to have a close fit to the normal distribution. Non-parametric models accomodate complex systems for which only a few of many variables can be measured.

For these reasons, non-parametric linkage analysis is the best approach to isolate candidate genes for Mendelian traits (Ott, 199 1). For cornplex nomMendelia traits, however, the non-pararnetric approach has rarely suseeded in identifying susceptability loci, probably due to the heterogeneity of these disorders (Heutink et al, 1995). The occasions when linkage analysis has successfully identified susceptibility loci, such as for severe bipolar disorder (Freimer ef al, 1996), the affected families studied have been selected for the presence of a founder effect documented to be present by a history of inter-rnarriage.

Given that linkage analysis of complex traits is only viable under some circumstances, association studies remain a usefül if limited tool for the analysis of complex traits. However, care must be taken in sample collection in order to be able to accommodate the assumptions of the parametric mode1 employed in association studies.

In addition it should be remembered that dike linkage studies, association of a rnarker with a disease, is not evidence that the gene under investigation, or an adjacent gene on the same chromosome. contributes to the inheritance of a disorder (Berrettini, 1997;

Hodge, 1994; Nothen et al, 1992).

In psychiatnc genetic assocaition studies, candidate genes studied ofien encode an important site of action for either an endogenous ligand or a drug used to relieve the symptoms of a disorder (Nothen et al, 1992). This is the approach we have used to select the DRDI, DATl and 5HTT genes for study in TS, AD-HD, OCD and alcohol dependence. The rationale for selecting each candidate gene will be explained below.

1.6 The dopamine bypotheses of TS, AD-HD and alcohol dependence Several lines of evidence suggest that TS, AD-HD and alcohol dependence are among

the neuropsychiatric disordee for which a dopamine hypothesis implicates the DRDl

gene and the DATl gene. The critical role of the DRDl and DATl gene products in

sustaining dopaminergic neurotransmission make these genes primary candidates for

neuropsychiatric disorders including TS (Gelemter et al. 1993), AD-HD (Cook et al,

1995; Cook et al, 1997) and alcohol dependence (George et al, 1995).

The DRD l gene, which encodes the dopamine D 1 receptor, is a member of the family

of genes that encode GPCRs. This receptor, while having 10 fold lower affinity for

dopamine than the dopamine D5 receptor (Sunahara et al, 1991), is important to

dopamine neurotransmission because of its greater expression in the striatal, cortical and

subcortical regions of the human brain (Sunahara et al, 1991). These regions are

implicated in ernotion, neuropsychiatric disorders and addictions (Weiner et al, 1991).

The DATl gene, which encodes the dopamine transporter, is involved in terminating

dopaminergic neurotransmission at the synapse. The human dopamine transporter gene

(DATI) belongs to a family of twelve transmembrane domain ~a and Cl- dependent

neurotransmitter transporters (Uhl and Johnson, 1994). The dopamine transporter, like

the other members of this family. is a presynaptic re-uptake mechanism (Ding et al, 1994;

Nirenbergh et al, 1996) that is integral to the termination of dopaminergic synaptic

transmissions by ~a+dependent reuptake (Kitayama et ai, 1992, Kilty et al, 199 1 ; Hom,

1990).

The DATI gene is implicated in the inheritance of TS (Comings et al, 1996;

Vandenbergh et al, 1992; Singer et al, 1991; Leckrnan et al, 1988) and alcohol dependence (Muramatsu and Higushi, 1995; Thiihonen et al, 1995; Devor and Cloninger,

1989), in addition to attention deficit-hyperactivity disorder (AD-HD) (Gill et al, 1997;

Cook et al, 1997; Comings et al, 1996; Cook et al, 1995), Parkinson's disease (Uhl,

1990) and schizophrenia (Bordea-Pean et al, 1995; Daniels et al, 1995; Li et al, 1994;

Penico et al, 1993; Losonczy et al. 1987). Abnormalities of dopamine transporter fhction have been proposed to contribute to both the hyperdopaminergic (Hom, 1990) and hypodopaminergic hypotheses of the dopamine pathogenesis of these disorders.

(a) The DATl and DRDl genes are candidates for TS

The effîcacy of D2-iike receptor antagonists, such as haloperidol, in alleviating the motor and vocal tic symptoms of Tourette's syndrome (Bruun and Budman, 1996; Wong ef al, 1996; Wolf et al, 1996) suggests that, as in schizophrenia (Van Tol rf al, 1992). a hyperdopaminergic pathology underlies TS (Barr et al, 1 996). The possible hyperdoparninergic state that underlies TS may be due to an increased number of dopamine receptors, increased receptor affinity for dopamine (Wolf et al, 1996; Cohen er al, 1978; Butler et al, 1978) or diminished termination of synaptic neurotransmission due to dopamine transporter pathology (Malison et al, 1995; Vandenbergh er al, 1992; Kilty et al, 199 1).

The DATl gene is a candidate gene in TS because its sequence variants may be responsible for the dopamine transporter dysregulation that is proposed to account for the hyperdopaminergic state that characterizes TS . The potential ro le of the dopamine transporter in TS is emphasized by the fact that a variety of psychostimulant drugs, such as cocaine (Kuhar et al, 1990; Wilson et al. 1996) and MP (Volkow et al, 1995) that bind

to the dopamine transporter have been reported to worsen the motor and vocal tics of TS

patients.

The DRDl gene is another candidate gene for TS because the hyperdoparninergic

state that is proposed to underlie TS may reflect the fact that TS patients have altered

dopamine D 1 receptor characteristics. Recent evidence from neuroimaging studies has

revealed that severely affected TS patients may have increased levels of DRD2

expression or aitered dopamine D2 receptor dupamine binding properties (Wong et al,

1997; Robertson, 1996: Wolf et al, 1 996). This suggests that dopamine receptors remain

valid candidates for TS. However, unlike the dopamine D2 receptor, no evidence of

altered DRDl gene expression in TS has yet been documented. The issue of whether

DRDl function is altered in TS can be investigated by attempting to isolate sequence variants of the DRDl gene in TS patients as has been done previously in schizophrenic

(Ohara et al, 1993) and bipolar patients (Shah et al, 1995).

Dopamine receptor genes have been studied as candidate genes in numerous association studies of sequence variants with TS. As with al1 association studies, moderate associations of dopamine receptor sequence variants (markers) have been taken as evidence that a hnctional polymorphic variant. perhaps in the 5' regulatory region. was in linkage disequilibrium with the marker. However, studies finding moderate association of the dopamine D2 (DRDZ), D3 (DRD3) and D4 (DRD4) genes with TS

(Comings et al, 1996; Grice et al, 1996; Comings et al, 1993; Cornings er al, 1991), remain controversial (Nothen et al, 1994; Barr et al, 1996). No evidence for linkage of the dopamine D 1 (DRD I ) and D5 (DRDS) genes with TS has yet been found (Gelemter et al, 1991 ; Barr et al, 1997).

Association studies. have not been conducted with DRDl in TS. However, snidies of the 5' flanking region of DRD 1 gene, including the Taq 1A prornoter polymorphism, have failed to show that the DRD1 gene is associated with schizophrenia (Cichon ei al, 1996) or bipolar disorder (Coon et al, 1993; Nothen er al, 1992). Point mutation analysis has recently confirmed that the DRDl gene coding region is non-polymorphic in schizophrenia (Lui Q et al. 1995) and bipolar disorder (Shah et al, 1995). However, studies searching for sequence variants of the DRDl gene coding region in TS patients have not been reported.

(b) The DATl and DRDl genes are candidates for AD-HD

The DRDl and DATl genes have also been implicated in the dopamine pathology that rnay underlie AD-HD. The hypodoparninergic hypothesis of AD-HD dopamine pathology (Gill et al, 1997; Cook et al, 1997; Cornings et al, 1996; Cook et al. 1995) has been inferred from the pharmacological evidence that psychotropic drugs, such as the dopamine transporter antagonist rnethylphenidate (MP) (Kuhar et al, 1990; Volkow et al,

1995; Wilson et al, 1996), effectively treat AD-HD (Ding et al, 1994; Hetchman et al,

1994). The hypodoparninergic hypothesis suggests that, by antagonizing the dopamine transporter, MP corrects the low synaptic dopamine levels that characterize AD-HD

(Ding et al, 1994), thereby prolonging dopamine receptor stimulation by dopamine. The

DRDl gene is therefore implicated in AD-HD because it encodes the dopamine Dl receptor which has high &nity for dopamine (Sunahara et al, 1990) and is highly expressed in the striatal and cortical brain region implicated in AD-HD (Volkow et al,

1995).

Traits such as dcohol dependence may also involve aberrant dopamine pathways (Ng er al, 1997; Noble, 1996; Tiihonen et al, 1995; Weiss et al. 1990). Dopaminergic neurotransmission in the limbic and mesolirnbic pathways of reward located in the midbrain, nucleus accurnbens and frontal cortex (Adamson et al, 1995) is implicated in the pathways of dmg reinforcement and reward that characterize alcohol dependence

(Strange. 1993; Sibley et al. 1992; Wise and Rompre. 1989; Koob and Bloom. 1988;

Wise, 1980). A hypodoparninergic hypothesis of alcohol dependence has been advanced

(Ng et al, 1997), that suggests that ethanol releases dopamine in some brain regions. thereby contributing to the rewarding and addictive properties of ethanol (Imperato and

Di Chiara, 1986; Ng et al, 1997). The identities of the dopamine system genes that may contribute to alcohol dependence, however, remain obscured by complex environmental factors (Cloninger, 1987; Persico et al, 1993; Muramatsu et al, 1995).

The DATl and DRDI genes are candidates for alcohol dependence because of their role in sustaining dopaminergic neurotransmission in brain regions implicated in the pathways of reward. Recent evidence that striatal dopamine transporter densities rnay be altered in alcohol dependent subjects (Tiihonen et al, 1995) raises the question of whether

DATl sequence variations contribute to altered dopamine transporter fiction in alcohol dependence. It is tempting to suggest that DATl or DRDl sequence variants may contribute to the hypothesized (Ng er al, 1997) effects of dopamine release into the synapse by ethanol. However, no information on the frequency of DATl coding region sequence variants is currently availabie. Information on the frequency of DRD 1 sequence variants in alcohol dependent patients is limited to a mutation screening of eight patients which, while revealing no mutations (Lui et al, 1995), cannot be considered to be conclusive given the small sample size.

1.7 The serotonin bypothesis

A number of neuropsychiatric disorders are characterized by serotonergic abnorrnalities. Severely affected TS patients have been found to excrete 5- hydroxyindoleacetic acid (SHTAA), the major serotonin metabolite, at higher leveis than found in controls (Bomstein and Baker, 1991). Post-mortern brain tissue from TS

(Anderson. 199 1) and depressed patients (Mann et al, 1996; Boyer and Feighner, 199 1) have been found to contain altered concentrations of serotonin compared to control post- mortem brain tissue. Evidence for serotonin metabolite dysregulation has aiso been identified in Type II alcohol dependent patients (Goidman, 1999, those with early onset and high genetic liability (Cloninger et al, 1989; Brown et al. 1985; Cloninger et al,

1985; Linnoila et al, 1983). In addition, serotonergic abnormalities have been noted in obsessive compulsive disorder (OCD) (Heils et al, 1996; Swedo and Leonard, 1994).

The serotonin transporter (SHTT) gene is a candidate gene in the study of the etioiogy of neuropsychiatric diseases considered to involve serotonergic abnorrnalities. Due to its role in clearing serotonin from the synapse, the serotonin transporter is integral to attenuating serotonergic neurotransmission (Heils et al, 1996). The efficacy of SRIs in treating neuropsychiatrie disorders, including unipolar depression (Ogilivie et ai. 1996;

Anderson and Tomenson, 19941, OCD, anxiety and depression comorbid with TS (Riddle et al, 1988), OCD (Swedo and Leonard, 1994) and alcohol dependence (Lejoyeux, 1996;

Narango and Bremer, 1994) suggests that the SHTT gene is a candidate gene in these disorders.

(a) The SHTT gene is a candidate for TS

The frequency with which TS patients are treated with SRIs in order to control comorbidities (Swedo and Leonard, 1994; Messiha. 1993), provides the pharmacological rational for examining the SHTT gene as a candidate gene in TS-OCD patients. Mutation screening, however, has shown that coding region variants of the 5HTT gene are very rare (Di Bella et al, 1996) and probably do not contribute to psychiatrie disorders. In this context the recently reported 44 base pair deletiodinsertion 5HTT promoter polymorphism is of particular interest because it has been shown to reduce SHTT gene expression in vitro (Heils et al, 1996; Lesch et al, 1996). Therefore, there is in vivo evidence that the sequence variant of the 5HTT promoter rnay be a mutation of the regulatory region of the 5HTT gene. This discovery raises the question of whether a polymorphism that has Functional significance in vitro. is also functional in vivo

(Paterson, 1997; Heils et QI, 1996). The hypothesis that the short promoter polymorphism may modulate serotonin transporter expression. thereby influencing the rate of serotonin clearance from the synapse in vivo (Heils et al, 1996), has not ken tested. Evidence that 5HTT mRNA expression may be increased in schizophrenics under neuroleptic treatment (Hemandez and Sokolov, 1997) suggests that 5HTT regulatory pathology rnay underlie some neuropsychiatric disease States. Similar evidence of altered 5HTT mRNA expression or aitered binding sites for serotonin antidepressant dmgs (Owens and Nemeroff. 1994). however, is not available for TS-OCD patients. However. nurnerous studies have used the candidate gene approach to conduct association studies of the 5HTT promoter in neuropsychiatnc disorder patient groups (Craddock and Owens. 1997).

Associations of the 5HlT gene promoter polymorphism with anxiety traits (Lesch et al? 1996) and depression (Collier er al. 1996) remain controversial (Ebstein et al. 1997) and unsupported. A snidy of the 5HTT promoter polymorphism in panic disorder found no association (Deckert et al. 1997). The serotonin transporter remains a candidate gene in anviety disorders and depression because of evidence for the efficacy of SRI treatment

(Ogilvie et al. 1996: Lejoyeux 1996) of the serotonin reuptake pathology (Collier et al.

1996; Iny et 02. 1994) that rnay underlie these disorders. The recent tentative association of the 5HTT with autism (Cook et al, 1997). a disorder fkequently characterized by OCD and anviety (Gordon et al' 1993; McDougle et al. 1996). suggests that other disorders treated with SRIs, including TS and its comorbidities. rnay also be associated with serotonegic dy sregulation (Messiha, 1993) involving the 5 HlT gene. (b) The SHTT gene is a candidate gene for alcohol dependence

Alcohol dependence withdrawal is charactenzed by severe anxiety and depression.

Both conditions can be relieved by SRIs. While anxiety has been associated with the

SHTT gene by studies of the 5HTT promoter alleles, depression has been associated with the 5HTT gene (Ogilvie et al, 1996) not by genotyping the SHTT deletiodinsertion polyrnorphism, but by genotyping the 5HTT intron 2 variable number tandem repeat

(VNTR). The fiequency of comorbid anxiety and depression in alcohol dependent patients (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1990) makes the 5HW gene a candidate for alcohol dependence.

1.8 Screening candidate genes for sequence variants

(a) Mutation screening by SSCP analysis

Single stranded conformational polymorphism (SSCP) analysis is a cornrnonly used method for the detection of gene sequence variants (Lee et al, 1992; Oto et al, 1993;

Hongyo et al, 1993). Cornrnon variants include single base pair changes, frameshift mutations, microsatellite polymorphisms and nucleotide insertions. Sequence information from muation screening is valuable because it provides evidence regarding the extent of amino acid sequence conservation in disease and control populations in addition to providing markers usehl in linkage and association studies (Weghorst, 1993;

Calvert et al, 1995). The method is based on the principle that when DNA is denatured, the single strands containing sequence variants assume a conformation different from those strands containing no sequence variants. The conformational differences in the single stranded DNA cm be resolved on polyacrylamide gel (Giavac and Dean. 1995;

Weghorst, 1993) as depicted in Figure 1. When an SSCP band shift is noted, sequence

analysis is then performed in order to identifi the nuture of a sequence variant.

The availability of pre-cast gradient polyacrylamide gels (Novex, San Diego, CA,

USA) that are nin in the Novex Xcell II minice11 system has resulted in improved efficacy of SSCP analysis (Hongyo et al. 1993). Many current protocols for SSCP, however, have not been modified to accommodate these gels (Bardeesy and Pelletier. 1995: Lam et ni,

1996). The initial phase of experimental work described here involved optimizing SSCP conditions for pre-cast gels.

1.9 Research objective: to screen candidate genes for sequence variants

(a) Isolate DATl gene sequence variants in TS and alcohol dependence

We set out to conduct the fint systematic mutation screening of the DATl gene in controls, TS and alcohol dependent patients. The DATl screening project is the logical sequel to the recent association of the DATl gene gene with TS (Comings et al. 1996),

AD-HD (Cook et al, 1997; Gill et al, 1997; Cook et al, 1995) and alcohol dependence

(Murarnatsu and Higushi, 1995). This study genotyped a variable number tandem repeat located 3' (3'VNTR): the only DATl polymorphism reported prior to our effort to screen the DATl gene (Vandenbergh el al, 1992). Therefore, the sequence information obtained from screening the DATl gene may be a valuable addition to what is known (3-

Genornic DNA PCR -=-,

Mutant

Denaturation

Single-stranded Conformations

Figure 1 The principle of PCR-SSCP analysis. Double stranded PCR products are generated for both wild-type (WT) and polymorphic/mutant (M) alleles. Follow-ing denaturation, the single strands refold to form specific secondary structures. Polyrnorphic/mutant single stranded DNA molecules have a different structure than the wild-type molecules. Polyacrylamide gel electrophoresis can resolve the two different wild-type strands and the two different polymorphic/mutant strands (Gdvac and Dean. 1995). about the DATl gene conservation in human populations (Donovan et al, 1995;

Vandenbergh et al, 1992; Gros et al, 1992). This sequence information will help to

evaluate the contribution of sequence variability in dopamine system genes to the

etiology of neuropsychiatric disorders.

(b) lsolate DRDl gene sequence variants in TS and alcohol dependence

We continued our study of the role of GPCR sequence variants in the etiology of TS

and alcohol dependence (George et al, 1993; Lam et al. 1996) by screening the coding

region of the DRD 1 gene for sequence vaxiants. While linkage analysis has excluded the

DRDl gene From having a major gene effect in TS (Heutink et al. 1995; Gelemter et al,

1993), by genotyping the 5'Taq 1A polymorphism no mutation screening of the DRDl coding region in TS has been reported in the literature. Evidence of a role for the DRDl gene in the inhentance of addictive disorders has recently been reported (Comings et al,

1997) but has not yet been replicated. No study has screened a Iage sarnple of alcohol dependent patients for sequence variants in the coding region of the DRDl gene (Lui et al, 1995).

Mutation screening of the SHTT gene in control and neuropsychiatric patient groups,

sirnilar to that which we conducted for the DATl gene, has shown that its amino acid sequences are conserved in patient and control groups. Di Bella et al, 1996, conducted a mutation screen in a number of neuropsychiatric patient groups. TS and alcohol

dependent patients, however, were not screened.

The evidence for conservation of SHTT coding region sequences in a number of

neuropsychiatric disorders suggested to us that rather than conducting a mutation

screenilg of the SHTT gene in our patient groups that it would be more f%utfuli to cary

out a candidate gene study of the 5HTT gene in TS and alcohol dependence. For this

purpose we genotyped the SHTT deletion.insertion polymorphism 5HTT and the intron 2

VNTR polymorphisms recently identified (Hiels et al. 1996; Lesch et al. 1994). The

5HTT deletionhsertion promoter polymorphism was of special interest because of evidence of its possible functional relevance. The intron 2 VNTR was genotyped in order to enable us to conduct haplotype analysis of the 5HTT gene in patient and control groups.

1.10 Research strategy for candidate gene screening and association studies

The candidate gene studies presented here were conducted in order to identiQ gene sequence variants unique to or significantly more common in patients compared to controls. Mutation screening projects inevitably identiQ a plethora of sequence variants that have no apparent functional significance. We therefore particularly sought to identify sequence variants of the DATl and DRD 1 genes that would result in alterations to the structure of their respective gene products. The discovery of novel sequence changes of undetermined significance requires pharmacological characterization in vitro by expression in ce11 lines (discussed by Hiels et al, 1996 and Lam el al, 1996) in order to establish whether altered protien sequence alters its function. Association studies of TS and alcohol dependence with the novel sequence variants were conducted while we continued to seek sequence variants leading to altered protien structure for characterization in vitro systems. ERIALS AND METHODS

2.0 Materials

Alkaline Phosphatase (Calf intestinal) Pharmacia Biotech (Baie d'Urfe, PQ)

Agarose Bio-Rad Laboratones

Ampicillin Sigma (St. Louis, MO)

Bacto Agar DIFCO Laboratones (Detroit, MI)

Programmable Power Supply Biorad, Mode1 3000Xi

Control DNA (not psychiatric/addicted) Addiction Research Foundation (Toronto,ON)

Control DNA (not psychiatndaddicted) Psychopharmacology and Dependence Unit.

Women-s College Hospital (Toronto, ON) Control DNA (addicted, not psychiatric) Psychopharmacology and Dependence Unit, Women's College Hospital (Toronto, ON) 7-deaza-deoxy-guanosine tri-phosphate Pharmacia Biotech (Baie d'Urfé, PQ)

Deionized Formamide Fluka (Ronkonkoma, NY)

Dimethyl sulfoxide (DMSO) Fluka (Ronkonkoma, NY)

DIOB Cornpetant Celts Mr. Tuan Nguyen

DNA Ligase Pharmacia Biotech (Baie d'Urfe, PQ)

Patient DNA (Tourette's syndrome) City of Hope Medical Centre (Durate, CA)

Patient DNA (Alcohol dependent) Addiction Research Foundation (Toronto, ON) pBluescnpt Strategene (la Jolla, CA)

PCR Genearnp Kit Perkin-Elmer Cetus (Norwaik, CT)

T7 Sequencing Kit Pharmacia-Biotech (Uppsala, S W) Polaroid Type 667 Film Eastman Kodak Co. and Polariod

Polyacrylamide Gel (6%) Helixx (Toronot, ON)

Polynucleotide Kinase, FPLCpureB Pharmacia-Biotech (Baie d'Urne. PQ)

Pre-cast 4-20% Acrylamide Gels Novex (La Jolla, CA)

Pre-cast 10% Acrylarnide Gels Novex (La Jolla, CA)

Restriction Endonucleases Pharrnacia/GIBCO B Ri,

SDS ICN (Dorval. PQ)

Taq Polymerase GIBCO BRL (Gaithersburg, MD)

Temperature Controlled Water Bath Haake (Karlsruhe, DR)

ThennoFlow SSCP System Novex (La Jolla CA)

Sequinase PCR Product Sequencing Kit USB (Cleveland, Ohio)

Ultrapure-dNTP Set Pharmacia-Biotech (Baie d'Urfie, PQ)

Xcell II mini-ceil system Novex (La Jolla CA) 2.1 DNA extraction

Following informed consent, blood samples were obtained from non-psychiatrie control individuals, patients with TS, TS-AD-HD. TS-OCD and alcohol dependence with no psychiatric comorbidity. The cnteria whereby these diagnoses were made are described below. Genomic DNA was extracted using phenol extraction and ethanol precipitation of DNA fiom patient blood as previously described (Bardeesy and Pelletier.

1995). Briefly. 5-10 ml of blood was added to an equal volume of lysis buffer (50 mbl

HEPES, pH 8. 50 mA4 NaCI. 5 mA4 MgC12. 10% sucrose. 05% Triton X-100) and the mixture was kept on ice for 10 minutes. The mixture was then centrifùged at 3000 g for

10 minutes. The supernatant was discarded and the pellet was resuspended in a mixture of TAE buffer and sodium dodecyl sulfate (SDS) before being incubated at 65 OC for 10 minutes. Fi@ ul of 10 mg/ml proteinase K and 50 lil of RNase A were then added before

incubating the mixture at 65 OC for 90 minutes.

Two extractions with equal volumes of phenol were performed by mixing the phenoVaqueous mixture for 30 minutes on a platform shaker. The aqueous phase fiom each extraction was saved and extracted rince more with equal volumes of phenol and chloroform before final extraction with an equal volume of chloroform. A one-tenth volume of 3 M sodium acetate in ethanol was then added to the aqueous phase. The DNA was then removed by spooling with a glas rod and nnsing in 70% ethanol before resuspending in TE buffer. 2.2 Clinical sam ples

(a) Tourette's syndrome sarnples

The TS group screened consisted of 109 unrelated patients recruited from the

Tourette's Syndrome Clinic of the City of Hope National Medical Center (COH). Durate.

California (Comings and Comings. 1993: Comings. 1994: Comings et al. 1996). The patients were selected to be Caucasians of Xorthem and Western European descent. All patients. and available relatives. completed a detailed behavioral questionnaire panemed after the Diagnostic Interview Schedule (DIS) (Robbins et al. 1981). The entire DIS questionnaire. and its use in other midies. is described elsewhere (Comings and Cornings.

1993: Comings et al. 1 996).

For al1 patients screened. the final diagnosis of TS. chronic motor and chronic vocal tic disorder. was made by assessing the variables required according to the DSM-III-R

(Diagnostic and Statinical 1 Manual of .Mental Disorders. Third Edition-Revised. 1987) and DS-M-IV (Diagnostic and Statistical .Manual of -Mental Disorders. Fourth Edition.

1990). In addition to the primary diagnosis of TS. 29 of the patients screened were diagnosed comorbidly uith OCD (TS-OCD) and 33 of the patients were diagnosed comorbidly with AD-HD (TS-AD-HD) according to the DSM-III-R (Diagnostic and

Statistical Manual of Mental Disorden. Thrd Edirion-Revised. 1987) and DSM-IV

(Diagnostic and Statistical Manual of .Mental Disorders. Fourth Editioa 1990) cnteria

Forty-seven of the TS patients had no comorbid diagnosis. The TS patients screened had not been included in previous studies (David Comings. personal communication). 34

The TS sample sizes varied for each gene that was screened or genotyped for two

reasons. First, DNA sarnples were still being obtained during the course of this study:

allowing sample sizes to increase &er the GPR19 and DRDl studies. Second, the PCR

reactions required to complete the SHTT gene study were less robust that those involved

in conducting the DATl study. As a result fewer patients were studied at the 5HTT locus

by cornparison with the DATl locus. The DATl gene was screened in al1 patients. The

DRDl gene was screened in 47 patients with a primary diagnosis of TS in addition to

three additional TS-OCD patients selected to be the next consecutive patients interviewed

(denoted by the COH patient identification nurnber).

(b) Alcohol dependence samples

DNA samples from 72 patients diagnosed with alcohol dependence were obtained fiom the Addiction Research Foundation (AM) of Ontario. The patients were diagnosed with alcohol dependence when admitted to the Toronto Hospital between 1989 and 1992 for alcohol-related chronic hedth problems. The assessrnent of alcohol dependence was made according to DSM-III-R criteria (Diagnostic and Statistical Manual of Mental

Disorders, Third Edition, Revised. 1987). The alcohol dependent group consisted of unrelated Caucasians of northem and western European descent who resided in the

Metropolitan Toronto Area (George et al. 1993).

A11 72 sarnples were screened for mutations in the GPR19 and DRDl genes. The

DATl gene was screened in 64 patients. The 5HTT gene was genotyped for the same 64 patients. The Bemoulie multiple testing corrections (discussed below) accounted for the fact that previous studies by our group have genotyped the DRD4 exon 3 polymorphism

(George et al, 1993) and the DRD2 Taq 1A polymorphism in the alcohol dependent group.

The GPR19 and DRDl mutation screening projects involved screening 50 nonpsychiatric control sarnples fiom the Addiction Research Foundation (ARF) of Ontario,

Toronto, Ontario. The subjects were described as being healthy volunteen From the

Metropolitan Toronto area with no history of psychiatnc treatment at the tirne blood was drawn.

For the study of the DATl and 5HTT genes in TS, groups of 67 and 91 nonpsychiatric controls respectively, were selected from the data-base of the

Psychopharmacology and Dependence Research Unit, Women's College Hospital,

Toronto, Ontario. Each control was ethnically matched to the TS group. The controls were genotyped for the 3'VNTR and the novel polymorphisms in exons 9 and exon 15 of the DATl gene and the deletionlinsertion and intron 2 VNTR polymorphisms of the

5HTT genes.

For the study of the DATl and SHTT genes in alcohol dependent patients, 64 controls were genotyped for the 3'VNTR and the novel polymorphisms of exons 9 and 15 of the

DATl gene. Of the total control group, the 15 exons of the DATl gene were screened for

42 controls obtained from the Addiction Research Foundation (ARF) of Ontario, Toronto.

Ontario. These controls were healthy volunteers from the Metropolitan Toronto area with no history of psychiatnc treatment at the time blood sarnples were taken. The rernaining

22 controls, selected using the same criteria from the data-base of the

Psychopharmacology and Dependence Research Unit, Women's College Hospital,

Toronto, Ontario, were genotyped for the YVNTR and the comrnon novel

polymorphisms in exons 9 and 15 of the DAT 1 gene.

2.3 PCR amplification of gene fragments subjected to SSCP muation screening

(a) Amplification of GPR19 gene fragments used to refine SSCP method

SSCP analysis of the GPR19 gene was conducted by amplifying the 1245 base pair

open reading frame (O'Dowd et al. 1996) into five overlapping Fragments using primer

pairs designed designed de novo for this purpose (Table 1). The PCR reactions were

conducted using 1 ug of each oligonucleotide primer (Table l), 2 umol dNTPI 1.5 mol

MgCI2 and 0.5 U Taq DNA polymerase (Life Technologies, Inc. Gaithersburg, MD) in a

total reaction volume of 100 ul. 200 ng of template was used per reaction. The PCR was

conducted in a Perkin Elmer Therocycler using 40 cycles, at 95 OC for 45 seconds. 55-6 1

OC for 45 seconds. and 72 *C for 1 minute 30 seconds. The arnplified DNA was analyzed

by agarose gel electrophoresis prior to mutation screening.

(b) Amplification of DRDl fragments to be analysed by SSCP

The pnmers used to amplifi the overlapping DRDl gene Fragments were designed de

novo for use in this screening project. SSCP analysis of the DRDl gene encoding the 446

amino acid dopamine Dl receptor (Sunahara et al, 1990) was conducted by arnplifying

the 1338 base pair DRDl gene coding region in five overlapping fragments using the TABLE. 1. Oligonucleotides Used in PCR-SSCPAnalysis of Hurnan GPR19 ge Fragrne Anneal

S Primer N Primer Sequence (5'-3') (base pa Temp. O 1 1 -UP TTCTTTTCCCCAACCAGAAT 32 1 6 1 2-DOW GGAATTGCCGAAGATAGAA 2 3-UP ACAGCCAGCATCTTCTTTGG 32 1 58 4-DOWN CCGGTCTATGCAGATGGA 3 5-UP ACTCCAGGTGTCCAGATCTA 32 1 60 6-DO WN TTGGTAAAATAAAATTATGAG 4 7-UP ACTGCCTACACTGTCATCCA 33 1 55 8-DOWN TTTCATCCCTCTCCGAAA 5 9-UP CCTACTCTGTATTCAATTTA 3 1 8 60 1 O-DOW AACAATTGAAAGAATGAG TABLE. 2. Oligonucleotides Used in PCR-SSCP Analysis of Human DRD 1 ge- Fragme Anneal

S Primer N Primer Sequence (5'-3') (base pa Temp. O 1 Pl-UP CTGCTTAGGAACTTGAGGG 321 60 P2-DOW GAAGCCAGCAATCTCAGCCAC 2 P3-UP CTGGTCATGCCCTGGAAGG 309 55 P4-DO W GGTCTCAGCCAGGGAAGTGGC 3 P5-UP CCAGTGCAGCTCAGCTGGC 414 60 P6-DO W CAAAATGCAGTTCAAGATGAA 4 P7-UP GTGTGCTGTTGGCTACTTTT 352 55 P8-DOW CAGGTCCTCAGAGGAGCCCAC 5 P9-UP AAGGAGTGCAATCTGGTTT 26 1 58 P 1 O-DO GCAAACCCCAGAGCAATCTCC primer pairs listed in Table 2. The PCR reactions were conducted using 200 ng human genomic DNA, 1 ug of each oligonucleotide primer (Table 2), 2mol dNTP, 1.5 mm01

MgCl2 and 0.5 U Taq DNA polymerase (Life Technologies, Inc. Gaithersburg, MD).

PCR was conducted using 40 cycles, at 95 OC for 30 seconds. 55-60 OC for 40 seconds. and 72 OC for 40 seconds in a Perkin Elmer Gene Arnp PCR Systern 2400 machine. The arnplified DNA was analyzed by agarose gel electrophoresis prior to the mutation screening.

The complete set of PCR primers used to ampliS. each DATl exon and the 3 ' and 5' flanking regions is listed in Table 3. The primers were designed from unpublished sequence information made available to us through our collaboration with the laboratory of George Uhl, National fnstitute on Dmg Abuse, Johns Hopkins University School of

Medicine (David Vandenbergh, personal communication). The PCR reactions were conducted using 200 ng human genomic DNA. 0.5 ug of each oligonucIeotide primer

(Table l), 2 umol dNTP, 1.5 rnrnol MgCl,, 10% DMSO and 0.5 U Taq DNA polymerase

(Life Technologies, Inc. Gaithersburg, MD) (Lam et al, 1996; Heiber et al, 1996;

Marchese et al, 1994). The 15 pairs of PCR primers used to ampli@ each exon are listed in Table 3. PCR was conducted using 40 cycles, at 95 OC for 30 seconds, 60-68 OC for 40 seconds, and 72 OC for 40 seconds in a Perkin Elmer System 2400 Gene Arnp PCR machine. The total reaction volume was 50 til. TABLE. 3. Oligonucleotide Pnmers Used in PCR-SSCP Anaiysis of Human DATl g Frag Anneal Name Primer Sequence (5'-3') Locati size ( temp " EX2ForB TGCCCTCCGCACCAGGTATG Exon 359 60 2C 1 CAAAGCCA ATGACGGACAG DAT CGTGGGACTCATGTCTTCCGTGG DAT 122s CCCCGGCTGCACCTACGAC EX3FOR ACGAGGAGAGATGGGCCCITCC EX3REV GTCACCACCATGATCCGCGC EX4FOR GTTGCTGATGGTGGCTCTGTGCT EX4REV GTCGCGCCATCTCTCCCG EXSFOR TTCCAGGTGGGTTGACAGCCTC EXSREV TTGGTGGCCCCATGTCTACAGG EX6FOR CCCACCAAGGGCCCTGCC EX6REV TGGGAATGCCAGAGCCCCTG EX7FOR CTCAGGTCC'ITTGCCTGTGGC EX7REV GACCTCTCCCTAGTATTGATGAGGCC EX8FOR ATTGCAGCTGCTGCAGCTCAGC EXSREV CGGCGCTGGTGCTACACGG EX9FOR GGCAAGCAGGGCGGGTTCTG EX9REV CGGGCGGTGCGGGTTACTC Ex 1 ORO GGCCCAGGCTGCGGTCAG EXlORE CCTGACAGTCCCAGCCAGGGC EX1 lFO CCCCAGGCTGGGTTTACCTCTGG EXIlRE GAAGGGGAGTGGCACAGCCACC EX12FO TGTCCAGCATCGGGGGAATG EX12RE GTGCCAGAGTGGGGGCAGTG EX13FO CCTGCTTTGTCCTGGCACCG EXl3RE GACACCCACGGAGCCTTTCTGG EX14For GGTCCTGACAGTGTGAGTCAGTGGTG EX 14Rev GGGCTAAGAACACTGAGCTTGGGATC EXISFO TGCTCTTAGCCACCTTCAGCTGCTC HDAT2 1 GGAGTCTTCTGCTTTGTTGTTTGTGTTTTCAG (d) Genotyping the DATl3'VNTR by PCR amplification

Amplification of the DATl 3'WTR was conducted using primers consisting of: T3-

SLong, 5'-TGTGGTGTAGGGAACGGCCTGAG-3' and T7-3aLong, 5'-

CTTCCTGGAGGTCACACGGCTCAAGG-3. Concentrations of PCR reagents in the

final reaction mixture were as described for amplification of DATI exons above. The

total PCR reaction volume was 50 irl. PCR was conducted using 40 cycles, at 94 OC for

30 seconds, 68'~for 40 seconds, and 72 OC for 40 seconds in a Perkin Elmer Gene Amp

PCR System 2400 machine. DNA was analyzed by 4% agarose gel electrophoresis in order to separate VNTR alleles of different sizes. Amplifieci DNA was visualized by ethidium bromide staining.

(e) Genotyping the SHTT polymorphisms by PCR amplification

The 5HTT promoter variant was arnplified using two sets of oligonucleotide primers.

Eighty-five DNA samples from TS patients and 9 1 TS controls. in addition to 61 of the

64 DNA samples fiom alcohol dependent patients and 32 controls were genotyped at the

5HTT promoter by ampliQing a 4841528-bp fragment using the prïmers stprj. 5'-

GGCGTTGCCGCTCTGPLATGC-3' and StrP 3 5'-

GAGGGACTGAGCTGGACAACCCAC-3'. The alcohol dependent DNA samples were genotyped at the SHTT prornoter by amplieing a 4061450-bp fragment using the primers

HTTpZA, 5'-TGAATGCCAGCACCTAACCC-3', and HTTpSB, j *-

TTCTGGTGCCACCTAGACGC-3' . The amplification of the 5HTT promoter was conducted using as little as 100 ng

human genomic DNA. One ug of each oligonucleotide primer, 2.0 mm01 MgClz 0.6 U

Taq DNA polymerase and 1X PCR buffer (Life Technologies, Inc. Gaithersburg, MD)

were used in each PCR reaction. Each reaction mixture contained 200 rmol of each

dNTP, with the exception of dGTP which was included at a concentration of 100 mole,

plus 100 zmole of 7'-deaza-dGTP. The total PCR reaction volume was 25 ul. PCR was

conducted using 40 cycles, at 94 OC for 30 seconds, 60 OC for 40 seconds. and 72 OC for

40 seconds in a Perkin Elmer Gene Amp PCR System 2400 machine. The amplified

DNA was analyzed by 4% agarose gel electrophoresis and the DNA amplified was

visualized by ethidiurn bromide staining pnor to photography over a UV light source.

The SHTT exon 2 VNTR was amplified for 75 controls matched to TS patients and

32 controls matched to alcohol dependent patients using the primers HTTZX, 5'-

TGGATTTCCTTCTCTCAGTGATTGG-3', and HTT2Y, y-

TCATGTTCCTAGTCTTACGCCAGTG-3'. to ampli@ the 345-bp (9 copy), 360-bp (10

copy) and 390-bp (12 copy) fragments of DNA encompassing the three alleles of the

VNTR. The VNTR of the 85 TS, 64 alcohol dependent, and 16 controls matched to TS

patients was amplified using the pnmers, S-CAATGTCTGGCGCTTCCCCTACATAT-

3' and 5'-GACATAATCTGTCTTCTGGCCTCTCAA-3'. The PCR products were

resolved in 4% acrylarnide gel and visualized by silver staining.

Amplification of the VNTR was conducted using 150 ng human genomic DNA, 1 ug of each oligonucleotide primer, 300 umol dNTP, 2.0 mm01 MgCl2, 0.6 U Taq DNA polymerase and 10% PCR buffer (Life Technologies, Inc. Gaithersburg, MD) per PCR reaction. The total PCR reaction volume was 25 ul. PCR was conducted using 40 cycles,

at 94 OC for 30 seconds, 57 OC for 40 seconds. and 72 OC for 40 seconds in a Perkin

Elmer Gene Arnp PCR System 2400 machine. DNA was analyzed by 4% agarose or 4%

acrylamide gel electrophoresis and then visualized by ethidium bromide staining or silver

staining respectively.

2.7 SSCP mutation screening of GPR19, DRDl and the DATl gene

(a) Overview of the SSCP methodology

Non-denaturing polyacrylamide gel electrophoresis was conducted on pre-cast 4-20%

gradient gels (Novex) in the Xcell II mini-ce11 system (Novex). In some cases the

ThermoFlow SSCP Electrophoresis System, consisting of an Xcell 11 mini-ce11 system adapted to allow temperature regulated electrophoresis. was used to optimize SSCP conditions. The T'hermoFlow re-circulates 1XTBE buf3er fiom the mini-ceIl through a condenser coi1 regulated by a temperature controlled water bath (Haake. Karlsruhe,

Gemany). Mutation screening efficiency was optimized (Oto et al. 1993) by screening each PCR product under at least two temperature conditions by adjusting the TBE buffer

temperature. SSCP was routinely conducted at 4 OC in the cold room and at 24 "C (room temperature). Intermediate or higher temperature SSCP (see results section) was conducted in the ThemoFlow.

Initidly, electrophoresis was conducted at 200 volts for 2 hours at 24 OC in the

ThermoFlow as indicated by recent protocols (Calvert et al, 1995). However, the majority of the SSCP analysis reported here was conducted at between 50-90 volts. Electrophoresis at 4 OC was conducted at 85 volts for 15-18 hours. At 24 OC the electrophoresis voltage was dropped to 55 volts in order to compensate for the faster

running time of SSCP conducted at 24 OC.

b) SSCP protocol adapted for use with Xcell II apparatus (Novex)

Between 3 and 6 u1 of the 50 ul PCR reaction was diluted 1 :4 with a formamide based

SSCP loading buffer in individual 0.2 uL micro-amp PCR tubes (O'Dowd et al, 1996).

The denaturing buffer was prepared before SSCP analysis by combining, in a 23 ratio, a stock denaturing solution with a stock stop solution. Both stocks were stored at room temperature. The denaturing solution was prepared with O. 1% SDS and 10 mM EDTA.

The stop solution was prepared with 95% formamide. 20 m.EDTA, 0.05%

bromophenol blue and 0.05% xylene cyanole FF. Samples were denatured at 95 OC for 5

minutes before being soaked at 4 OC in the PCR machine for 5 minutes prior to loading on acrylamide geI (O'Dowd et al. 1996).

The entire 20 ul mixture of denaturing buffer and PCR product was loaded into the separate wells of Novex 4-20 % TBE gels (Novex, La Jolla, California). Most SSCP was run in the cold room or at room temperature, as described. DC Power was supplied by a Biorad, Mode1 3000Xi Programmable Power Supply (Richmond, CA). A proportion of the total PCR products amplified frorn patient and control DNA sarnples were selected for repeated analysis in the ThemoFlow SSCP Electrophoresis System at other temperatures. The Novex SilverXpress Staining kit was used to visualize SSCP band shifts. Sequencing of the PCR products corresponding to SSCP band shifts was done as descnbed below (O'Dowd et al. 1996).

2.8 Identification of sequence variants by chain-termination DNA sequencing

PCR products identified by SSCP to be potentially polymorphic were subcloned into pBluescnpt. transformed into E. Coli competant cells (strain DIOB), grown ovemight in

LI3 broth with ampicillin before miniprepping and sequencing the PCR insert as previously described (Marchese et al. 1994).

2.9 Statisticai Methods

The differences between the genotype and allele fiequencies of the TS and alcohol dependent groups and theii respective control groups were analyzed by two-tailed a' tests using the Statistical Package for the Social Sciences (SPSS). version 7. Hardy-

Weinbergh equilibrium for the genotypes at each locus was tested using x2 analysis as done previously (Kennedy el al, 1995). The Bonferroni correction for multiple testing was used in order to account for testing associations at three loci of the DATl gene and two loci of the 5HTT gene (Aickin and Gensler, 1996). Analysis of sample power was conducted using the Epi Infio, Version 5.01 a (Public Domain Sofrware for Epiderniolo~ and Disease Surveillance, March 1991). Linkage disequilibriurn between haplotypes consisting of the cornmon polymorphisms and the 3'VNTR was analyzed using the maximum likelihood Equilibrium Haplotype (EH) (Terwilliger and On, 1994; Ott, 199 1) program. RES_ULTS

3.1 SSCP mutation screening of the GPRl9 gene

The SSCP rnethodology used to screen candidate genes in this project was refined by

screening GPR19 in the 50 caucasian controls and 72 caucasian alcohol dependent

patients described in the context of the DRDl gene mutation screening project. The

purpose of this preliminary screening work was two-fold. First, we were interested in

establishing the optimal SSCP conditions for screening candidate genes for sequence

variants. Second, we were interested in determining whether polymorphic sequence

variants of GPR19 existed

GPR19 is an intronless gene that encodes a 414 amino acid gene producr. Our

interest in GPR19 stemmed fiom the fact that the GPR19 gene has many of the

chxacteristics of neurotransmitter G protein-coupled receptors (O'Dowd ei al, 1 993).

Hydrophobie analysis suggests that the deduced arnino acid sequence of GPR19 has the

seven transmembrane (TM) regions characteristic of GPCRs. The expression of GPRl9

in the olfactory tubercle, the islands of Calleja, the caudate-putarnen, and the pituitary suggests that GPR19 encodes a neurotransmitter receptor with a pattern of expression similar to the dopamine D2 receptor. The fact that 10 1 amino acids of the GPR19 gene product were identical to those of the dopamine D2 receptor is further evidence that

GPR19 is likely to encode a neurotransmitter receptor. However, no ligand for the

GPR19 receptor has yet been identified.

Screening GRP19 revealed a number of single base pair nucleotide changes. The combination of extended SSCP gel running time and reduced voltage was found to result in more consistent resolution of DNA sequence variants by SSCP conducted on 4-20% pre-cast polyacnlamide gels (Novex). SSCP detected a silent MG polymorphism at nucleotide 1062 of the GPR19 gene of a control subject when samples were nin at 4 OC at

85 volts for 15 hours. This polymorphism was detected by the presence of an additional band (Fig. 28, lane 2) in the portion of the SSCP gel resolving both single stranded (SS)

DNA and double stranded (DS) DNA. The polymorphism was poorly resolved, however, when the samples were electrophoresed at 24 OC at 55 volts for 9 hours (Fig.2 C). The rapid SSCP protocol (300 volts, 2 hours) did not resolve this polymorphism (Fig. 2A, lane 2). niese results demcnstrate the importance of controlling temperature and voltage conditions in order to ensure sensitive resolution.

The effect of SSCP running temperature on the resolution of sequence variants is also illustrated in Figure 3. SSCP analysis run at 4 OC for 15 hours at 85 Volts resolved band shifts that were revealed by sequencing to be homozygous (Fig 3A, lane 2) and heterozygous (Fig 3B, lane 2) forms of a T/C nucleotide change at base pair 250 located in the portion of GPR19 encoding the putative second transmembrane (TM2) domain.

The nucleotide change resuiting in the band shifis in Fig 3 was detected by SSCP in less than 2% of the 114 DNA samples screened. The nucleotide change resulted in a conservative Val l l6Ile amino acid change. The sarne heterozygous polymorphism

resolved in Fig 3B, lane 2 was also resolved by SSCP analysis run at 24 OC. however, the pattern is very different.

Figure 4 shows the SSCP analysis of the portion of GPR19 encoding the putative third transmembrane (TM3) domain of the receptor. The SSCP band shifis shown here Figure 2 Optimization of SSCP temperature, ninning tirne and voltage to resolve variants. SSCP analysis of GPR19, run at 4 OC at 85 volts for 15 hours, detected a polymorphism (B, lane 2). Note the presence of an additional band in the portion of the SSCP gel resolving both single stranded (SS) and double stranded (DS) DNA. The polymorphism was poorly resolved at 24 OC at 55 volts for 9 hours (C, lane 2). Rapid SSCP (300 volts, 2 hours) did not resolve this polymorphism (A, lane 2). Figure 3 The effect of SSCP ninning temperature on the resolution of sequence variants. The SSCP analysis run at 4 OC resolved band shifts revealed to be homozygous (A, lane 2) and heterozygous (B, lane 2) forms of a T/C nucleotide change in GPR19. The heterozygous polymorphism (B. lane 2) resolved into a different pattern when SSCP was conducted at 24 OC (C,lane 2). Figure 4 Resolution of sequence variants in TM3 of GPR19. Variants were detected by SSCP nui at 24 OC but not at 4 OC. The SSCP gel was run at 50 volts for 15 hours using the SSCP conditions discussed. were detected at 24 OC but not at 4 OC. The band shifis were present in nearly 7% of the

DNA sarnples anaiyzed. Sequencing showed that this nucleotide change of CiT at base pair 300 resulted in a conservative arnino acid change fiom Ile289Val.

In the course of refining the SSCP protocol. various polyacrylamide gels were compared for their ability to detect a single nucleotide change. Resolution of the cornmon GPR19 polymorphism on pre-cast polyacrylamide non-gradient 10 % gels was iderior to resolution on 4-20% gradient gels (Figure 5). The 10 % gels were electrophoresed with 60% of the voltage used to run SSCP 4-20% graciient gels. however, high SSCP band shift resolution was not maintained. Therefore, fùrther use of SSCP to screen for sequence variants in candidate genes was undertaken using 440% polyacrylarnide gels.

The above results represent our first experience with conducting SSCP on pre-cast polyacrylamide gels. The resolution appeared superior compared with that used in Our lab by Lam et al, 1996 to screen the SHTIA receptor for sequence variants in TS patients.

The GPRl9 gene was found to be highly conserved in patients and controls.

3.2 SSCP mutation screening of the DRDl gene

The SSCP analysis involved screening the entire coding region of the DRD 1 gene for sequence variants using SSCP conditions that were found to be effective in screening the

GPR19 gene for sequence variants. No SSCP band shifts were noted in the TS (n=50), the TS-AD-HD (n=35), the TS-OCD (n=30) and the alcohol dependent (~72)patient groups when SSCP was conducted at 55 volts for 18 hours at 24 OC or at 100 Figure 5 Resolution of TM3 variant on 10% gels was inferior to that on 4-20% gels. When 10% gels were run at 60% of the voltage used to run gradient gels, SSCP resolution was not maintained. volts for 18 hours at 4 OC. One band shift was observed in the SSCP analysis of the

portion of the gene coding for the amino terminus of the DRDl gene in one of the 50

controls matched to the Tourette's syndrome population (Figure 6. lane 2). The SSCP

analysis was conducted at 100 volts for 18 hours at 4 OC. Sequence analysis of the DRD 1

gene in 3 representative patients fiom each patient and control group confirmed that the

SSCP band shifi observed for the control subject analysed in figure 6, lane 2 was caused

by a base pair substitution of C for T which resulted in the conservation of 49Ile. This sequence was not found among the patients screened.

3.3 SSCP mutation screening of the DATl gene

The DATl gene mutation screening project was ambitious because of the size and complexity of the gene. The DATl cDNA encodes a large 620 amino acid protein. encoded by 15 exons and introns of which al1 exons but the first are translated. The size of the DAT 1 introns remains unknown. However, published (Donovan et al, 1995) and unpublished (Vandenbergh, persona1 communication) intron-exon junction sequence information enabled us to screen the DATl gene by subjecting the PCR products amplified using the pnmers listed in Table 3 to SSCP analysis. This procedure presented difficulties for those primer pairs that amplified more than one DNA product. For this reason, the pnmers for exons 4, 10 and 12 were designed more than once before the set presented in Table 3 successfûlly amplified the correct gene fragment.

The structure of the DATl gene was analyzed by SSCP in 225 subjects. Band shifts were noted in al1 groups when exon 2 (using primer pair EX2ForB and 2C 1, Table Figure 6 Analysis of a fragment (350 bp) of the D 1 receptor gene. This silent mutation was only detected by electrophoresis conducted at 85 volts for 24 hours at 1 OC. The arrow indicates the pattern of a polymorphic varient. 3) was analyzed by SSCP conducted at 55 volts for 18 hours at 24 OC (Fig. 7 A, lane 1).

Sequence analysis showed that the band shift was due to a sequence variant 171C/T that did not result in an amino acid change. The individual analyzed in lane 1 was revealed,

by sequencing, to be heterozygous.

In addition to the silent 171C/T polymorphism, a rare nucleotide change was also discovered in exon 2 (Fig 7. lane 3) in a single control subject. Sequence analysis showed that this band shifi was the result of a 164T/C nucleotide substitution that results in a relatively conserved arnino acid change Va1 164AIa in this control subject.

A second conservative amino acid change was also discovered in another control subject. Sequencing confirmed that the SSCP band shifi in exon 8 (Fig 8, lane 1).

resolved by 50 volt electrophoresis for 12 hours at 30 OC. resulted from a sequence variant 1445TK. A Val 1 144Ala amino acid change resulted. The individual analyzed in

Fig 8' lane 1 was heterozygous for this sequence variant.

SSCP band shifts were also noted in al1 groups when exon 9 (Fig 9) and exon 15 (Fig

10) were analyzed by SSCP conducted at 100 volts for 18 hours at 4 OC on 440% gradient gels. Sequencing revealed that the exon 9 SSCP band shifi (Fig 9, lane 2) resulted from a hornozygous sequence variant 1215NG that did not result in an amino acid change. Sequencing identified the individuals in lanes 1 and 3 to be homozygous non-polymorphic and heterozygous for the polymorphism respectively. The exon 15

SSCP band shift (Fig. 10, lane 1) was confirmed to result fiom a homozygous sequence variant 1898T/C downstream of the translated portion of exon 15. Sequencing confirmed Figure 7 SSCP analysis of DATl exon 2 in three control subjects. Sequence analysis showed that the SSCP band shift in lane 1 was due to a silent sequence variant 171 CR. This individual was revealed, by sequencing, to be heterozygous. A rare nucleotide change was also discovered in the patient analysed in lane 3. Sequencing showed that this SSCP band shift reflects a 164TK nucleotide change in exon 2, resulting in a conservative arnino acid change Va1 1 64Ala in this control subject. Figure 8 SSCP analysis of DATl exon 8 in three control subjects. The band shift in lane 1 was found to reflect a 445T/C sequence variant that results in a Va11 144Ala amino acid change. The individuai analyzed in lane 1 was heterozygous for this sequence variant. Individuals anaiyzed in lanes 2 and 3 were shown by sequencing to be non-polymorphic. Figure 9 SSCP analysis of DATl exon 9 in dire TS subjects. Sequencing revealed that the exon 9 SSCP band shifi in lane 2 resulted from a homoqgous 1215NG sequence variant that did not result in an amino acid change. Sequencing identified the individuals in Ianes 1 and 3 to be hornozygous non-polymorphic and heterozygous for the polymorphism respectively. Figure 10 SSCP analysis of DATl exon 15 in three control subjects. The band shift in lane 1 was confirmed, by sequencing. to result fiom a homozygous sequence variant 1898TIC Iocated downstream of the translated portion of exon 15. Sequencing confirmed that the individuals analyzed in lanes 2 and 3 were non-polymorphic and heterozygous for the exon 15 poiymorphism respectively. that the individuals analyzed in lanes 2 and 3 were non-polymorphic and heterozygous

for the exon 15 polymorphisrn respectively (Giros er ai, 1992; Vandenbergh et a[, 1992).

In order to complete the project, patients and controls were genotyped for a

polymorphic 3'VNTR marker at the DATl locus (Vandenbergh et al, 1992). Three

alleles of the 3'VNTR were identified (Figure 1 1). Lane I shows the 480 base pair band

identified to be homozygous for the 10 repeat allele (1 0/10) of the 3'VNTR. Lane 2

shows the 480 base pair band and the 442 base pair band below it. This individual was

heterozygous for the 10 repeat and the 9 repeat aileles (1019) of the 3'VNTR. Lane 3

shows a 150 base pair band which identifies an individual homozygous for the 3 repeat

ailele (3/3) of the 3'VNTR.

3.4 Association study of DATl polymorphisms in TS and alcohol dependence

Allele frequencies of the novel polymorphisrns are shown in Table 4. The frequency of the exon 2 polymorphism was between 3.7% and 6% in the TS (n=47), alcohol dependent (n=64) and control groups (n=42) (Table 4). Because of its low frequency. we did not genotype our remaining patient and control samples for the exon 2 polymorphism.

The frequencies of the cornmon polymorphisms in exons 9 and 15 were determined in al1 patient and control groups (Table 4).

The exon 9 A.G fiequencies were 19% and 23% in TS and control groups respectively. The frequency of the exon 9 T/C polymorphism was 33% in the alcohol dependent group and 24% in the matched control group. Xhalysis(Table 4), however, Figure 11 PCR genotyping of the DATl 3'VNTR. Lane 1 was found to be a 480 base pair band homozygous for the 10 repeat allele (1 0110). Lane 2 shows the sepmation of the 480 base pair band and the 442 base pair band below it. This individual was found to be heterozygous for the 10 repeat and the 9 repeat alleles (1019). Lane 3 shows the 150 base pair band identifying an individual homozygous for the 3 repeat allele (313). ?'-LE 4. DATl allele and genotype frequencies: X'P values compare population frequencies Population Exon 2 N Frequency Genotype Frequencies x2pvalues C/T 1-1 1-2 2-2 3x2 3x3 Tourette's 1 09 0.037 0.926 0.074 O Control 42 0.06 0.88 O. 12 O -

Alcoholics 64 0.047 0.906 0.094 O Control O - -

Exon 9 Allele 1 Genotype Frequencies xLpvalues Population MG N Frequency 1-1 1-2 -3-2 3x2 2x2 Tourette's 1 09 0.77 0.59 0.37 O .O3 0.494 0.494 Control 67 0.8 1 0.64 0.3 0.06

Alcoholics 64 0.67 0.42 0.5 0.08 Control 64 0.76 0.53 0.36 0.0 1

Exon 15 Allele 1 Genotype Frequencies x2pvalues PopuIation T/C N Frequency 1-1 1-2 -7-1 3x2 2x2 Tourette's 109 0.79 0.63 0.32 0.05 0.677 0.677 Control 67 0.75 0.57 0.37 0.06

Alcoholics 64 0.73 0.5 0.47 0.03 Control 64 0.76 0.56 0.46 0.0 I

S'VNTR 3'VNTR Genotype Frequencies X~P Population (48 bp), N 10/10 9/ 10 9/9 2/10 39 *Other 3x2 3x3 Tourette's 1 09 0.66 0.29 0.05 O O 0.05 0.767 0.767 Control 67 0.6 1 0.3 1 0.06 0.02 O 0.08

Alco holics 64 0.53 0.42 0.0; O 0.02 0.05 0.934 0.933 Control 64 0.56 0.3 8 0.03 0.03 O 0.06

3'VNTR compared by using 10/10, 9/10 and *Other genotpyes to generate X' P value. indicates that the difference between exon 9 A/G allele frequencies and exon 9 A/G genotype frequencies was not significant between patient and control groups.

The exon 15 T/C frequencies were between 21% and 27% for both patient (TS and alcohol dependent) and control groups. X2 analysis (Table 4) indicated that the exon 15

TIC fiequencies and genotype frequencies were not significantly different between patient and control groups. Genotype and allele fiequencies were also found not to be significantly different between the TS group with no comorbidity, the TS-OCD group and the TS-AD-HD (X2~values ranging from 0.283 through 0.872). Al1 patient and control groups were found to fit closely to Hardy-Weinbergh equilibnum at each of the three polymorphisms genotyped, including the YVNTR. This concurs with the fact that although the DNA was obtained fkom 4 sources, the patient and control subjects were ethnicaily matched. The X2~values ranged fiorn 0.1 (exon 9 A/G in alcohol dependent patients), through 0.97 (exon 15 T/C in TS).

Linkage disequilibrium between DAT 1 haplotypes was also analyzed. The lO/9 repeat polyrnorphism of the 3'VNTR (VNTR 10/9), found at similar allele and genotype frequencies in each group (Table 4), was in linkage disequilibriurn with the exon 15 polymorphism in the TS group (x2=6~.91. 5df, pK1 the alcohol dependent group

(X1=19, jdf, p

X2=18.42, 5df, p<.104). For the exon 15 T/C-VNTR 10/9 haplotype, linkage disequilibriurn coefficients 6 were O. 1 1 for TS patient and control groups and 0.10 for alcohol dependent patient and control groups. The modest disequilibrium coefficient 6 values, on an absolute value scale fiom 0-0.25, suggest that, while significant disequilibrium exists for the exon 15 A/G-VNTR 1019 haplotype, not al1 individuais with

the exon 15 TIC allele have the VNTR IO19 allele on the same chromosome.

In the TS group, linkage disequilibrium was aiso found between the exon 9

polymorphic allele and the 3'VNTR (X2=18.73.5 df, p<4* 104) and between the exon 9

and exon 15 polymorphic alleles (X2=12.72, 3 df, p

6 were 0.7 and 0.6 for the exon 9 NG-VNTR 1019 and exon 9 NG-exon 15 T/C

haplotypes respectively. The more modest 6 values for these TS haplotypes compared to

those of the exon 15 T/C-VNTR 1019 haplotype suggests that, while statistically significant, the exon 9 A/G-VNTR 1019 and exon 9 A/G-exon 15 TIC haplotypes are iess fiequent. No evidence for linkage disequilibriurn was found between these alleles in either the control groups or the alcohol dependent group.

3.5 Association study of SHTT polymorphisms in TS and alcohol dependeuce

The deletiordinsertion SHTT promoter polymorphism and the 5HïT intron 2 VNTR polymorphism were genotyped in al1 patient and control groups (Figures 12 and 13). The allele and genotype fiequencies are surnmarized in Table 5. X2 analysis showed that genotype frequencies at both loci fit closely to Hardy-Weinbergh equilibrium for patient and control groups. For the bi-allelic promoter locus, XZ~values ranged fiom 0.26 (for the alcohol dependent group) to 0.92 (for the TS group). For the tri-allelic intron 2

VNTR locus, X2~values ranged corn 0.1 1 (for the TS group) to 0.80 (for the alcohol dependent group). Figure 12 Deletion/insertion SHTT promoter polymorphism genotyped on 4% agarose. Lane 1 shows the PCR product (-484 bp) of an individual homozygous for the short promoter. Lane 3 shows the PCR product (-528 bp) of an individual homozygous for the long promoter. Lane 2 shows PCR products for the long and short promoter arnplified from an individuai heterozygous for the long and short promoters. Figure 13 Intron 2 VNTR polymorphism genotyped on 4% agarose. Lane 1 shows a PCR product (-390 bp) homozygous for the 12 copy (390 bp) . Lanes 2 and 3 show two band shifts for a patient heterozygous for the 12 copy and 9 copy (bp) alleles. Lane 4 shows the two band shifts of a patient heterozygous for the 12 copy and 10 copy (bp) alleles. The SHTT promoter deletion (the short promoter) was significantly more common in

the TS group (51%) compared with the control group (36%) (X2=8.77, 2 df. p=0.04. two

tailed, Bonferroni corrected). Genotype fiequencies were not significantly different

between the TS and control groups (x'=8.45, 2 df. p=0.18, two tailed) afier Bonferroni

correction even though the homozygous shon genotype was twice as cornmon in the TS

group (26%) compared to the control group (13%). Odds Ratio for short promoter allele

association with TS was 1.88 [95% CI 1.2 1-2.931).

The short promoter allele was not significantly more fiequent (X'=1.52. 2 df, p=0.22, two tailed) in the alcohol dependent group (45%) compared to its matched control group

(37.5%). Although the homozygous shon promoter alleie was more fiequent arnong alcohol dependent patients (28%) compared with the matched control group (16%), the genotype Frequencies were also not significantly different benveen the patient and control groups (X2=1 83.2 df. p=0.40, two tailed).

The allele and genotype frequencies of the intron 2 VNTR were not significantly different between the TS group and matched control group (X'=4.09. 2 df. ~0.129.two tailed; X2=6.37, 3 df, p=0.1, two tailed), as reported in Table 5. Between alcohol dependent and control groups, however, the allele frequencies (X'=20.56, 1 df, p=7.2* 10-

5 . two tailed, Bonferroni corrected) and genotype frequencies (X'=25.08, 3df, p=0.0006. two tailed, Bonferroni corrected) were significantly different, as reported in Table 5. The

Odds Ratio for an alcohol dependent patient having the 10 copy allele was 5.80 [95% CI

2.42-14.371. TABLE 5. 5HTT allele and genotype frequencies: X'P values compare patient and control frequencies deletion/ N Frequency Genotype Frequencies X2p values Group insertion 1-1 1-2 7-3 3?2 2,V Tourette's 91 0.47 O .24 0.50 0.26 0.04 0.18 Control 91 0.64 O .42 0.45 O. 13

Intron 2 VNTR Genotype Frequencies X2p values Group VNTR N 12/12 10/12 10/10 9/12 9/10 919 9/AlI 4x2 2.V Tou rette's 109 0.44 0.37 0.05 O O 0.05 0.05 0.10. O. 13. Control 67 0.44 0.28 0.08 0.05 O 0.09 O. 14

Alcoholics 64 0.25 0.53 0.18 0.023 0.025 0 0.05 6'10'' 7.2'[0-5 Control 32 0.62 0.20 0.03 O. 16 O O O- 16

SHTT innon VNTR genotype frequencies (4,V) compared 124'1 2, !O/ 12. iO/IO and 9iAll other alleles to jenerate X- value; SHTT allele frequencies (3x2)compared the fiequency of the 10 copy allele to the combined frequencies of al1 other alleles. Linkage disequilibrium between the deletiodinsertion polymorphism and the intron 2

VNTR polymorphism was analyzed in each patient and control group. No evidence of linkage disequilibrium between the polyrnorphisrns was found in the TS group or its control group (%'=2.5 1. 5 df, p=0.5; X'=0.20, 5 df. p=O.j). Linkage disequilibrium was significant between the polyrnorphisrns in the alcohol dependent group (X'= 15.67, 5 df, p=0.004) but not in its control group (%'=O.19, 5 df, p-0.5). In the alcohol dependent group, the linkage disequilibriurn coefficient S was 0.1 for the haplotype consisting of the

(insertion) long promoter- 10 copy VNTR allele. This modest disequilibrium coefficient

6 value suggests that while statistically significant only partial linkage disequilibrium is present for the short promoter-10 copy haplotype. lDlSCUSSION

4.0 Interpreting candidate gene sequence vanants in patient and control groups

(a) Consenrationof the DRDI gene in TS and in alcohol dependence

No systematic atternpt to associate strucniral variations in the coding region of the

DRDl gene with TS, aicohol dependence or related disorders has appeared in the literature. The present midy has largely ruled out the possibility that mutations in the coding region of the DRDl gene contribute to the etiology of TS or alcohol dependence in the patients studied. The DRDl sequence conservation among the 72 alcohol dependent patients reported here confirms the results of a previous study on the DRDI gene in eight aicohol dependent patients (Lui et al, 1995). The integrity of the DRDl gene coding region among TS patients confirms the results of a previous study on the role of the DRDI gene in TS (Gelernter et al, 1993).

The previous work on the DRDl gene in TS was limited. however. by being confined to analyzing RFLP sites fond in the regions flanking the DRDl gene (Gelemter et al.

1993). The present study. by contrast, effectively excludes the possibility that DRDl coding region mutations contribute to the etiology of TS or aicohol dependence by systematicdly screening the DRD I gene.

(b) DATl gene sequence variants in TS and in alcohol dependence

The DATl gene mutation screening examined whether sequence variants in the coding region of this gene underlie the polygenic inheritance of TS (Gelemter et al, 1995:

Comings et al, 1996), AD-HD (Gill et ai, 1997; Cook ei al, 1995) and alcohol dependence (Persico et al. 1993: Muramitsu et al. 1995). This study has succeeded in

identifying structurai variants in the coding region of the DATl gene that map help to

clari- association studies of the YWTR of the DATl gene with TS (Comings et al.

1996). .4D-HD (Cook et al. 1997: Gill et al. 1997: Cook et al. 1995) and alcohol

dependence (Muramatsu and Hiphi. 1995).

The DATl gene variants. however. are not likely to result in altered dopamine

transporter function. The two lare arnino acid changes. Val54Ala and Val164Ala are

consewative and were found in control subjects. Three common single nucleotide

polymorphisms were identified: exon 2 Cm. exon 9 A/G and exon 15 TIC. These

poly~oorphismswere not found at significantly different allele or genotype frequencies in

the TS or alcohol dependent groups bp %' analpis (Table 4). Therefore. the novel DATl

polymorphisms do not appear to be associated with TS or alcohol dependence. Power

analysis (specifuinp a type II error rate of ad.05 and power of 1$=O. 80), indicates that patient and control groups of the size used in this study are large enough to detect

hypothetical odds ratios of 2.3 and 3.35 for the DATI eson 9 A/G and exon 15 TIC alleles to be risk alleles for TS (n=109) and alcohol dependence (n=64) respecrively.

Future studies should genotype larger patient and control sample groups in order to \-en@ that these polymorphisms are not associated with TS or alcohol dependence.

Previous studies (Comings et al. 1996: Gelemter el al. 1995) suppon the evidence presented here that the DATl gene is not associated with the vocal and motor tics considered to be the essential features of TS (Diagnostic and Statistical Manuai of Mental

Disorden. Fourth Edition. 1990). However. the earlier work by Comings et al. 1996. did associate the DATl VNTR l0/10 genotype with 1-2% of AD-HD diagnosed comorbidly

with TS. In the present study. this association was not detected by analysis of the

frequency of the VNTR 10110 genotype in TS patients diagnosed comorbid with AD-KD

(n=33) compared with TS groups with no AD-HD cornorbidity (n=86). Future studies should examine large samples of TS-AH-HD patients in order to confirm the lack of association between DATl and TS-AD-HD found here.

Statistically significant, partial linkage disequilibriurn was found for the exon 15 TIC-

VNTR 1019 haplotype in al1 patient and control groups. This suggests that the exon 15

T/C marker may be of use in friture haplotype based Haplotvpe relative nsk (HH-RR) studies of TS and aicohol dependent trios. Differences in linkage disequilibrium between patient and control groups were noted. Partial linkage disequilibrium for the exon 9 NG-

VNTR 1019 and exon 9 NG-exon 15 T/C haplotypes was statistically significant in the

TS group but not in either control group or the alcohol dependent group. However. linkage disequilibrium must be compared with caution between groups of unrelated individuals because a control group unrelated to the patient group cannot control for recombination events that result in different linkage disequilibria in different populations

(Tenvilliger and Ott. 1994). The linkage disequilibriurn between the novel DATl polymorphisms, therefore, should be used to examine the family-based association of TS with the DATl gene as done previously in studies of AD-HD (Gill et al, 1997; Cook et al, 1997).

The results of the DATl candidate gene mutation screening represent a necessary step

(Gelman and Gelemter, 1993) toward understanding whether a candidate gene. such as the DATl gene, contributes to the inheritance of a disease state. Our SSCP anaiysis of

the DATl gene, like the recent SSCP andysis of the norepinephrine transporter (NET)

(Stober et al, 1996), discovered sequence variants comrnon to control and disease States.

These polymorphisms rnay clarie studies of the phmacology of MP, cocaine (Volkow

et al, 1999, antidepressants and endogenous catecholamines (Buck and Amara, 1995)

because there is now evidence that amino acid variants, while comrnon in the NET gene, are rare in the DATl gene. Research into the selective phmacology of the dopamine and norepinephrine transporters using transporter chimeras (Buck and Amara, 1 995;

Buck and Amara, 1994) may be particularly usehl in determining the significance of

DATl sequence conservation.

The DATl sequence information, therefore, facilitates Merstudies of dopamine transporter pharmacology (Volkow et al, 1995), the pharmacogenetics of cocaine addiction (Gelemter et al, 1994; Persico et al, 1993) and future Iinkage studies of the

DATl gene in TS, alcohol dependence and other neuropsychiatrie disorders including

AD-HD. Should evidence of linkage or Iinkage disequilibrium between disorders and the DATl gene be confi~rmed, a good case could be made for searching for polymorphisms in the 5' regulatory sequences that may contribute to the dopamine transporter pathology (Singer et al, 1991 ; Tiihonen ef al, 1995) that may underlie these disorders. (c) Association studies of SHTT variants in TS and in alcohol dependence

We have presented work that provides preliminary evidence that the 5HTT gene may

be a susceptibility loci for TS. X' analysis (Table 5) detected a significant difference

between allele fiequencies (~~=8.75,1 df. p=0.04, two tailed, Bonferroni corrected) but

not genotype fiequencies ($=8.45, 2 df, p=O. 18, two tailed, Bonferroni corrected) of the

5HTT promoter between TS patient and control groups. The Odds-Ratio of 1.88 for TS patients to have at least one short 5HïT promoter allele, suggests that the 5HTT short prornoter may be a risk ailele for TS. Ninety-five percent confidence intervals of 1.21-

2.73, indicate that the Odds-Ratio is above unity. Power analysis (speciSing a type II error rate of a=0.05 and power of 1-B=0.80), indicates that patient and control groups of the size used in this study are large enough to detect an odds ration of 2.4: a value toward the upper Iimit of the 95% confidence interval of 1.21-2.73 of the Odds-Ratio for a TS patient to have at least one short 5HTT promoter risk allele.

The discussion of the results of this study of the SHTT prornoter in TS would not be complete without comparing the frequency of the SHTT short promoter allele in our control group with that in control groups genotyped for other studies. In the control group used for this study (n=9 l), the short promoter allele frequency was 36%. However, other studies have found the short promoter at higher fiequencies. A study of the short dlele in 90 German controls and 79 Itdian controls found this allele at frequencies of

41% and 42% respectively (Deckert et al, 1997). A study of the short allele in 104

English, 301 Italian and 95 German controls found its frequency to be 45%, 43% and 40% respectively (Collier et al, 1996). Therefore, replication of this work is necessary in

order to confimi the control frequency of the 5HTT short promoter allele in the caucasian

nonpsychiatrk control population. This issue must be considered because a common

weakness of association studies in psychiatric genetics has been the fact that statistically

significant associations can result from genotyping confounded control groups. even

when an attempt to match patients and controls for ethnic origin has been made (Pato et al, 1993; Barr and Kidd, 1993).

The intron 2 VNTR, previously associated with unipolar depression (Evans et al,

1997; Ogilive et al, 1996) but not associated with manic depressive illness (Bellivier et al, 1997), was also genotyped for both of our patient and control groups. VNTR allele and genotype fiequencies were not significantly different in the TS group compared to the control group, however, both the alleles and genotypes of this locus were significantly different in the alcohol dependent group (n=64) compared to its control group (n=32)

(~~=22.79,2 df, p=l .2* 1O-', two tailed, Bonferroni corrected; X2=25.08,4 df, p=7* 1O-', two taileci, Bonferroni corrected).

The control group assigned to the alcohol dependence group was small. Therefore, we attempted to verify our analysis by comparing the alcohol dependent VNTR allele and genotype fiequencies to those of the control group (n-91) that was originally assigned to the TS patient group. This cornparison also found a significant difference between allele and genotype frequencies (X'=16.64, 2 df, p=0.003, two tailed, Bonferroni corrected;

X2=20.83,3 3df, p=0.0012, two tailed, Bonferroni corrected), although the X2~values are larger. This analysis is not strictly valid because the large control group was not originally assigned to the alcohol dependence group. However, it serves to codirm that the VNTR allele and genotype frequencies are different between the alcohol dependent patient group compared with both of our control groups.

Our VNTR findings for alcohol dependence are different From those reported (Ogilvie et al, 1996) in the study associating the SHTT VNTR with depression. The depression study found that the 9 copy VNTR allele was associated with risk for unipolar depression.

Our study, on the other hand, found that an excess of the 10 copy VNTR allele was significantly more common than the combined 12 and 9 copy VNTR allele group (Table

5) in alcohol dependent patients (n=64) compared to controls (n=32). This analysis was repeated using the larger control group (n=91) that was not originally assigned to the alcohol dependent group. Again, the 10 copy VNTR allele was significantly more cornmon that the combined 12 and 9 copy allele (%'=17-95, Idf, p=0.003, two tailed.

Bonferroni corrected), although the association was less significant (X'~values were larger). The Odds Ratios of 5.80 [95% CI 2.42-14.371 and 2.85 [95% CI 1.69-4.8 11 were calculated for the risk of an alcohol dependent patient having the 10 copy allele, compared with controls from the small and large groups respectively. Therefore. our study suggests that the 10 copy allele may confer risk for alcohol dependence by an unknown mechanism that may invoive adjacent gene stuctures.

The VNTR association should be interpreted with caution, however, because the intron 2 VNTR has no known effect on the 5HTT gene at the transcription level. While alleles of the YVNTR of the insulin gene have been shown to correlate with its transcription (Pugliese et al, 1997), there is no evidence as yet that the SHTT VNTR alleles have any regulatory fünction (Ogilvie et al, 1996). The role of Activator Protein-l

(AP-1) motifs adjacent to the 5HTT WTR remains speculative (Ogilvie et al, 1996;

Lesch et al. 1994).

In addition, the SHTT intron 2 VNTR has not been genotyped in large enough numbers (Evans et al, 1997; Ogilvie et al, 1996) to know the VNTR allele fiequency in the caucasian population. Because depression is frequently comorbid with alcohol dependence (Anton, 1996), our result showing an excess of the 10 copy VNTR allele in alcohol dependence may conflict with the previous study showing that an excess of the 9 copy VNTR alleie is associated with depression (Ogilvie et al, 1996). Power analysis

(speciQing a type II error rate of a=0.05 and power of 1-P=0.80), however, suggests that our alcohol dependent and control sarnples are large enough to be able to detect the Odds

Ratios for the 10 copy VNTR allele calculated. This work needs to be independently repeated in order confirm these findings because the phenomenon of population stratification (Barr and Kidd, 1993) has been known to confound studies that have attempted to use unrelated controls matched for ethnic otigin (Barr and Kidd, 1993;

Kennedy et al, 1995).

It has previously been suggested (Ogilvie et al, 1996) that evidence of 5HTT VNTR association with disease might indicate linkage disequilibrium of the VNTR with a functional mutation (Ogilvie et al, 1996). This study found evidence that linkage disequilibriurn for the short prornoter-VNTR IO copy haplotype is present in the alcohol dependent group (6=0.1), but not in TS or control groups. However, the association of the short promoter with alcohol dependence does not reach statistical significance. Power analysis suggests that alcohol dependent and control groups are large enough to detect an

odds ratio of three if it were present.

While this sîudy does present evidence of linkage disequilibrium in the alcohol

dependent group that may be disease associated, it ought to be remembered that linkage

disequilibrium should be compared with caution between unrelated individuals

(Twenvlliger and Ott, 1994). A fùture study should genotype mother-father-proband

trios in order to assess whether the short promoter-VNTR 10 copy haplotype is associated

with alcohol dependence. Transmission of the short promoter allele in TS trios rnay also

be informative about the role of the 5HTT gene in TS.

4.1 Conclusions

We have succeeded in confirming the practicality of using SSCP to identifi sequence variants of as little as a single base substitution under the conditions developed to screen the GPR19 gene. nefact that SSCP has previously been demonstrated to identim 85-

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Weghorst et al, 1993) allows us to conclude that we have identified the majority of the sequence variants of the candidate genes we screened in patient and control groups. We have used SSCP to effectively exclude the role of sequence variants in the DATI and

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