Some Reflections on the Genetics of Mental Disorder by INGRAM F
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Some Reflections on the Genetics of Mental Disorder by INGRAM F. ANDERSON. M.B.B.Ch.(RancL) Department of Medicine and Clinical Genetics Unit, Johannesburg General Hospital. "Heredity, the only one of the Gods whose real Whereas psychiatric genetics previously name we know . brings gifts of strange tem- appeared to be an empiric exercise and its peraments . and impossible desires." — applications in mental disease were thought Oscar Wilde. to denote a state of irreversibility, it now A study of aberrant mental mechanisms provides a point of vantage for research and involves consideration of the interaction of therapeutic application. Thus a genetically the soma, psyche and multiform environ- determined biochemical disturbance may not ment. Such a vast field cannot be surveyed only point the way to new means of diag- critically or even adequately in a disserta- nosis but offers possibilities of correction at tion of this nature. The title of the paper is the molecular level. thus employed advisedly: "some" because With these introductory remarks it will be the scope is necessarily limited, "reflections" propitious to pass on to a consideration of because here are mirrored my thoughts and (A) Mental Deficiency and (B) The Psychoses. those of others which may not be true images, "genetics" indicates etiologic restric- (A) MENTAL DEFICIENCY. tion and "mental disorder" is used in the broad sense. About one out of every thousand whites in The average medical-man, like the man in this country is in a mental asylum because the street, has very little occasion to come of mental deficiency. The problem comprises up against cases of mental abnormality. The elements of considerable philosophic and latter are locked away early — out of harm's social importance; it provokes the question ) of why people are different and what deter- 2 way, out of society's way, out of medicine's 1 mines their individuality; it limelights the 0 way . However most of the major ad- 2 paradox of human rights and raises the vances in genetics and especially in cyto- d polemic aspects of eugenics as these reflect e t genetics in the last few years have evolved in the mirror of human ecology. a d against this very background and notably ( r within its parameters, as exemplified in the Almost half of the institutionalised cases e h case of mongolian idiocy. The recent splurge are simple oligophrenics. So-called simple s i l of spiders across the erstwhile neatly-lined mental deficiency involves the genetics of b u pages of the medical journals has seemed to intelligence. The latter is a tenuous entity, P many to represent the soap-bubble interest dependent on multifactorial inheritance and it e h of a narrow speciality. On the contrary, the is safe to say that its precise nature remains t y implications have been widespread and a matter of controversy. One reads in the b diverse, and have impinged upon the whole book of Job: d e t broad structure of medical-biology. n "But where shall Wisdom be found? a It is noteworthy that the layman has al- r And where is the place of understanding? g ways been aware of an hereditary component Man knoweth not the price thereof; e c in mental illness, as evidenced by everyday Neither is it found in the land of the living. n The deep sayeth it is not in me e statements such as, "There's madness in X's c i And the sea sayeth it is not with me. l family. Comes through the father's side it It cannot be gotten for gold, r e does!" The medical world has been tardy in Neither shall silver be weighed for the price d thereof. n accepting such a situation and only in the u Whence then cometh Wisdom? last few decades has it given concrete for- y And where is the place of 'understanding? ..." a mulation to the concept. The current explo- w e sion of activity and interest in human gene- For our purposes, we note that the simple t a tics has again focussed attention on the moron has no distinctive characters and sta- G domain of the psychiatrist. tisically lies at the negative end of the t e n i b a S JOURNAL OF THE SOUTH AFRICAN LOOPEDIC SOCIETY 1 y b d e c u d o r p e R Gaussian distribution of intelligence. In con- On the smallest time scale are events at trast to this somewhat ubiquitous entity, the dynamic intracellular level. Interest here great strides have been made in our under- centres on the chromosome constitution. In standing of two definitive types of mental man each cell contains 46 chromosomes: 22 defect, namely, mongolism and phenylketo- pairs of autosomes and a pair of sex-chromo- nuric oligophrenia. somes. In 1959 Lejeune and his co-workers discovered that the mongol possesses an ex- (1) Mongolism. tra autosome — a state of aneuploidy (i.e. an abnormal number of chromosomes). Basically It is convenient to discuss this in terms of two mechanisms underlie the chromosomal a collocation of the three time factors in the aberrations in mongolism: non-disjunction biologic picture. On the largest scale is Evo- and translocation. Non-disjunction is the lution, with Man the result of a long line of common type. During meiosis there is failure ancestors and himself the potential ancestor of separation of two homologous chromo- of a long line of descendants. The interest somes. Thus one daughter cell will come to here is historic. When Langdon-Down pub- contain both components of an autosome pair lished his classic paper on "An Ethnic Clas- and the other cell neither. The former, after sification of Idiots", in 1866, he described fertilisation will be trisomic (i.e. it will have Mongolism for the first time, characterising three instead of two of a certain chromo- the mongol as, "... a representative of the some, in this case number 21 on the Denver great Mongolian race". Crookshank in 1931 classification), and will have a diploid num- added the hypothesis that these cases were ber of 47. This situation is seen typically derived from Mongolian ancestors and fur- with older mothers and may be related to ther that they represented an atavistic return mechanical factors operating in an old ovary towards the orang-utang. There is no scien- with "old" ova. Less commonly translocation tific validity for this idea and the anomaly occurs. This involves the breakage of two can be readily recognised in the Mongol race non-homologous chromosomes and an ex- itself. Because of this confused inference change of fragments between them. The attendant on the name, the designation Lang- greater part of chromosome 21 becomes don-Down Syndrome has been preferred by attached to one or other fragment leading to ) many. a normal diploid number of 46, but in fact 2 1 there exists a virtual trisomy 21. In addition 0 On the intermediate time-scale we consider 2 translocation allows of the formation of a d the individual as such — his life history. e carrier state and the defect may therefore be t Mongolism exceeds all other morbid condi- a perpetuated through several generations. In d tions of severe mental retardation in number, ( essence then, whatever the mechanism, an r constituting some 5 to 10% of asylum in- e additional chromosome is overtly or occultly h mates. There are approximately 125 mongols s i present. A great many genes — each con- l at the institution at Witrand. The incidence b trolling specific metabolic processes — lie u in the population is nearly one in every 600 P a'on^ its length. However, the relationship e births. As a comparative measure it is salu- of the cytology to either the biochemistry or h t tory to note that the incidence of hyperten- to the pathology remains obscure. It is impor- y sive disease is 5%, of all forms of congenital b tant to realise that the mongol is abnormal d heart disease about 1%, while myelomatosis e from the moment of conception. A degree of t accounts for 3 per 100,000 of the population. n developmental irreversibility is attendant at a ι r birth and therapy must therefore be more or g The child with mongolism is usually born e less ineffective, there is no rationale for the c into a normal family with parents and n use of thyroid extract, alpha glutavite, sicca- e siblings ofjten above average intelligence. An c i cell therapy (injection of dried foetal brain l enormous j psycho-social problem is at once r cells) or large doses of vitamin E. e generated \ and cannot be elaborated upon d n here. Apart from the mental subnormality, (2) Phenylketonuria. u mongols jexhibit extensive physical ab- y a normality,, proneness to infection being quite A somewhat brighter vista is revealed w e a feature. The advent of the antibiotic era when we look to the inborn error of meta- t a has seen a rise in the mean survival age of bolism, phenylketonuria. This is the G the mongol. paradigm of a genetically determined en- t e n i b a December, 1962 JOURNAL OF THE SOUTH AFRICAN LOOPEDIC SOCIETY S 1 y b d e c u d o r p e R zyme-block. It is transmitted as a single mental disintegration. The same basic pro- autosomal recessive, the homozygous state cess is believed to underlie the endogenous being necessary for phenotypic expression. psychoses, but it is far more subtle, as yet The enzyme, phenylalanine hydroxylase, is elusive and cannot be so elegantly demon- at fault and there follows failure of oxidation strated.