Carol A. Tamminga - US grants

This competitive renewal grant application proposes both laboratory and clinical research projects to follow up and continue a productive line of research in neuroleptic-induced dyskinesia pathophysiology and GABA- mediated neuronal transmission. Our findings to date have led us to formulate a "working" hypothesis of neuroleptic-induced dyskinesia pathophysiology in haloperidol treated animals. We currently aim to test this idea further in rats and to explore this mechanism in schizophrenic patients with TD. Eventually, this could lead to an understanding of the pathophysiology of tardive dyskinesia (TD) and provide a small animal dyskinesia screen for new antipsychotic drugs. In addition, we have demonstrated a therapeutic effect of clozapine in TD and now are seeking to understand whether clozapine improves dyskinesias in TD through diminishing these same neuroleptic-induced GABAergic changes in the substantia nigra pars reticulata (SNR) and whether other clozapine-like antipsychotic drugs will also treat tardive dyskinesia. In this grant, we propose to pharmacologically test our "working" hypothesis for the mechanism of haloperidol-induced rat oral dyskinesias. This hypothesis suggests that in rats with oral dyskinesias (not in nondyskinetic animals) an elevated dendritic release of dopamine in the SNR releases GABA from striatonigral GABA-containing neurons at a presynaptic D1 receptor to overinhibit the GABA/A receptor-bearing GABAergic nigral efferent neurons which project to thalamus. Also, we propose to evaluate new (ie "atypical") neuroleptics in the rat oral dyskinesia "model" we have developed, for their association with oral dyskinesias in rats. In clinical studies, we propose to test the new antipsychotic drug olanzepine for efficacy in schizophrenia with tardive dyskinesia, using the design with which we showed a therapeutic action of clozapine in TD. And, in clinical postmortem study, we propose to further evaluate our working hypothesis of tardive dyskinesia pathophysiology; here we will examine measures of dopaminergic and GABAergic transmission in basal ganglia postmortem tissue from schizophrenic patients with and without TD using similar biochemical markers as were positive in our animal dyskinesia studies. We propose that these studies will help advance our overall goals of understanding-the mechanism of -TD and developing treatments for-the disorder.

This project will study the pharmacokinetic characteristics of haloperidol in schizophrenic patients after acute administration and the relatioships between drug dose, drug levels in plasma and CSF, and clinical response during fixed-dose subchronic treatment periods. Approximately 40 patients will be studied over three years; they will manifest a variety of symptoms of schizophrenia and comprise a range of subcategories of the syndrome (e.g. paranoid, disorganized, deficit state, undifferentiated). Several hypothesis have already been raised to account for the poor drug-level/clinical-response correlation obtained by others: neuroleptic-resistant psychosis, reflecting pharmacologic heterogeneity among schizophrenics; response correlations studied in conditions of neuroleptic drug excess; and individual differences in drug compartmentatlization. Participants in this study will be inpatients hospitalized for reasons of their psychotic condition who have a diagnosis of schizophrenia or schizoaffective psychosis; patients will include those with acute and chronic illness, with differences in neuroleptic history (type and duratio), and a spectrum of major symptomatic manifestations. Each patient will receive a complete diagnostic workup with baseline ratings to be repeated during the treatment phases. After a four week neuroleptic-free period, a 24 hour plasma drug level curve will be generated following a fixed 20 mg oral dose of haloperidol. Subsequently, three, fixed-dose treatment phases of one month's duration each will be carried out; treatments will be placebo, low dose (0.1 mg/kg.day), and moderate dose (0.3 mg/kg/day) in random order. Plasma drug level, CSF drug level, and clinical ratings of psychosis and side effects will be done during the last 1.5 weeks of each treatment period. The data will be analyzed to see whether characteristics of the acute metabolism of haloperidol predict drug-induced psychosis changes. Furthermore, the data will explore any significant relationships between drug plasma level, CSF drug levels, and clinical response: in diagnostic and symptomatic sub-groups, between other drug compartment measures, or with lower neuroleptic dosage. These data may lead to improved pharmacotherapeutic management of schizophrenic psychosis.

Chronic neuroleptic treatment is associated with various tardive and withdrawal manifestations in the human patient which are generally ascribed to dopamine (DA) receptor supersensitivity. Although well studied in the experimental animal, little clinical biochemical or neuroanatomic data have been collected in the living human patient to explain human tardive or withdrawal syndromes. Therefore, we propose to study 30 schizophrenic patients (15 with and 15 without tardive dyskinesia) using positron emission tomography (PET) with fluoro-deoxyglucose (FDG) before, and during a one month course after neuroleptic withdrawal. The abrupt neuroleptic withdrawal design was chosen to stimulate or intensify the regional metabolic changes associated with chronic neuroleptic treatment. Patients with and without tardive dyskinesia were included to compare the regional metabolic changes associated with "tardive," as compared to "non-tardive," conditions. All individuals in this protocol will receive three PET/FDG scans: before, 3-5 days after, and one month after abrupt haloperidol withdrawal. In addition, clinical assessments of mental status (BPRS) and motor function (MPRC scale), and sleep and biochemical (plasma prolactin and homovanillic acid) measurements will be done before and throughout the withdrawal period. Changes in regional cerebral glucose uptake with abrupt neuroleptic withdrawal (3-3 day post withdrawal scan) will be compared with the regional glucose uptake during chronic treatment and at the "drug-free" point (4 week post withdrawal scan). These PET/FDG changes will be correlated with maximum alterations in sleep characteristics and biochemical measures during the withdrawal period. In a pilot study, sleep characteristics, prolactin concentrations, and dyskinesia scores changed in a predicted "supersensitive" pattern with abrupt neuroleptic withdrawal; mental status responses have been more individualistic. These data have provided the impetus for studying PET/FDG alterations over the course of neuroleptic withdrawal in patients with and without tardive manifestations. In the future, we would hope to study the biochemical basis of the PET/FDG withdrawal changes more precisely as they might explain these tardive phenomena.

Discovery of the antipsychotic efficacy of dopamine (DA) receptor antagonists in the early 1950's initiated several decades of research into the regulation and control of DA-mediated neural transmission in mammalian brain (1). Now, a considerable body of knowledge has accrued about CNS DA systems, including their circuitry, biochemistry, regional specificity, and receptor diversity, to suggest additional and perhaps more sophisticated approaches to their pharmacologic manipulation (2). The development of specific pharmaceutical agents to selectively affect particular components and distinct receptors of the dopaminergic system has been initiated (3,4). Hence, it is now possible to apply novel pharmacologic strategies involving the DA system to the treatment of neuropsychiatric illnesses, like schizophrenia. This grant will propose 1) the evaluation of several partial DA agonists in actively-psychotic drug-free schizophrenic patients to test their antipsychotic activity; 2) the evaluation of these drugs in deficit schizophrenia with low dose thioridazine, to test their activity in the negative symptoms of the illness; and 3) clarification of the relationship between the intrinsic activity of those different partial DA agonists and their clinical behavioral and biochemical characteristics in the human patient. Partial DA agonists are a putative novel antipsychotic strategy. Their full clinical activity in schizophrenia remains to be defined. There is evidence in the literature that partial agonists have antipsychotic properties. We have completed additional confirmatory studies with (-)-3PPP. As DA agonists, however, the drugs should lack any hypokinetic side effects, and lack the delayed-onset dyskinesias prominent with neuroleptics, because the drugs have a measure of agonist activity at the DA receptor. The theoretical rationale for antipsychotic action, and the preliminary data testing some of these partial agonists in schizophrenia, appear positive. However, since partial agonists can vary widely in their partial agonist activity (from 1% to 99% of the activity of dopamine itself; with apomorphines for example, having 63% intrinsic activity), there are a range of partial agonists to pick from. This application proposes the testing of three different partial agonists in schizophrenia (with and without concomitant neuroleptic and in different phenomenologic subtypes), each drug with varying levels of intrinsic activity; two, to be tested immediately and the third to be selected and tested in later years.

The strategy of using partial dopamine (DA) agonists as antidopaminergic antipsychotic agents is based on two sets of observations: first, that DA neurons have autoreceptors which function to decrease DA synthesis, release and neuronal firing and hence are antidopaminergic; and, second, that partial agonists have full affinity but reduced DA receptors, consequently they exert relatively lower receptor stimulation in competition with the natural neurotransmitter, dopamine. We have suggested that antipsychotic treatment with partial DA agonist, compared with full receptor antagonists may have clinical advantages, if these drugs can be shown to be effective. Efficacy and side effects of partial DA agonist will depend on the level of intrinsic of the partial agonist, a range which can extend from less than 10% to over 90%. Our work to date (see Progress Report) suggest that a partial agonist activity somewhat below 35% may be optimal to test in schizophrenia. Our most useful partial DA agonist at present is (-) -3PPP. The strategy of combining a small proportion of a full antagonist (eg. haloperidol) with the partial agonist (-) -3PPP, to produce a functionally lower intrinsic activity of (-)-3PPP, adds flexibility to our clinical testing of the partial agonist strategy. Since the respective roles of the D2, D3 and D4 receptors in mediating the antipsychotic action of neuroleptics is still unknown, we remain interested in discriminating actions at these receptors in psychosis and in agonist action. Our clinical studies will focus on testing the antipsychotic action of two different levels of (-)- 3PPP functional intrinsic activities, each evaluated in the three primary symptom clusters of schizophrenia: 1) hallucinations/delusions; 2) thought disorder; and 3) negative symptoms. Also, since dopamine agonists have different levels of intrinsic activity at each D2-family receptor, we need to determine which (or perhaps all) of the receptors to target for antipsychotic effect with a given intrinsic activity. Therefore, we propose to test the antipsychotic action full antagonists of the D3 and D4 receptors in schizophrenia on the three primary symptom clusters depressions (hallucinations/delusions; thought disorder; negative symptoms), to identify the role, if any, of these receptors inn the control of psychosis. In the laboratory, we propose to use the D2,l, D3, and D4.4 cloned receptors in cultured CHO or HB-108 cells to examine the intrinsic activity and the desensitization potential of different DA agonists at the human receptors, in vitro. These data will predict and later help us to select optimal agonist intrinsic activity a depression family receptor for clinical testing with respect to antipsychotic activity, duration of therapeutic action, and side effects. Lastly, in the laboratories, we propose to determine the functional consequences of selective D2, D3, and D4 receptors types in rat and human brain (see Progress Report) we will explore the distribution activation following selective receptor blockade as measured by IEG expression.

schizophrenia; neurochemistry; clinical chemistry; biomedical facility; GABA receptor; antipsychotic agents; mental disorder diagnosis; mental disorder chemotherapy; disease /disorder model; model design /development; drug metabolism; brain metabolism; brain imaging /visualization /scanning; neurotransmitter metabolism; phencyclidine; haloperidol; high performance liquid chromatography; laboratory rat; vole; single cell analysis; magnetic resonance imaging; experimental brain lesion; immunocytochemistry; human subject;

schizophrenia; neurochemistry; clinical chemistry; biomedical facility; GABA receptor; antipsychotic agents; mental disorder diagnosis; phencyclidine; haloperidol; disease /disorder model; model design /development; brain metabolism; brain imaging /visualization /scanning; drug metabolism; neurotransmitter metabolism; mental disorder chemotherapy; functional magnetic resonance imaging; experimental brain lesion; laboratory rat; immunocytochemistry; single cell analysis; human subject; high performance liquid chromatography; magnetic resonance imaging; positron emission tomography;

The strategy of using partial dopamine (DA) agonists as antidopaminergic antipsychotic agents is based on two sets of observations: first, that DA neurons have autoreceptors which function to decrease DA synthesis, release and neuronal firing, and hence mediate antidopaminergic signals; and, second, that partial agonists have full affinity but reduced intrinsic activity at DA receptors, consequently they exert relatively lower receptor stimulation in competition with the natural neurotransmitter, dopamine. The investigators have suggested that antipsychotic treatment with partial DA agonists, compared to treatment with DA receptor antagonists may have significant clinical advantages. Efficacy and side effects of partial DA agonists will depend on the level intrinsic activity of the partial agonist, a range which can extend from less than 10 percent to over 90 percent. The investigators work to date (see Progress Report) suggests that a partial agonist activity somewhat below 40 percent may be optimal for schizophrenia. The investigators most useful partial DA agonist is (-)-3PPP. The strategy of combining a small proporb'on of a full antagonist (e.g. haloperidol or clozopine) with the partial agonist (-)-3PPP, to produce a functionally lower intrinsic activity of (-)-3PPP, adds flexibility to the clinical testing of the partial agonist strategy. The investigators first clinical study will focus on testing the antipsychotic action of a very low dose of haloperidol (0.5 haloperidol + (-)-3PPP (flexible dose range) or (-)3PPP placebo, compared to a third active control arm (5 mg bid haloperidol + (-)-3PPP placebo). Treatment in each of these three aims will be evaluated in the three primary symptom cluster of schizophrenia: 1) hallucinations/delusions; 2) disorganization, and 3) negative symptoms, and on cognitive function. Our second study will be designed exactly like the first study, except that a very low dose of clazopine will be utilized. Clazapine is low affinity tigand and may, in combination with (-)-3PPP, produce a better antipsychotic action based on its greater displacability. Because the investigators have already demonstrated significant efflcacy, but efflcacy to which tolerance occurs, the investigators current goal is to demonstrate that the efficacy of (-)-3PPP treatment, by modifying intrinsic activity and dosing schedules can be extended. If the investigators are able to overcome the efficacy tolerance, then one of these treatments would be ready for broader multicenter testing. Application of this strategy to other syndromes where neuroleptics improve psychosis is also indicated. In the biochemistry laboratory, we propose to use the D2', D4 2. D4 4 and D4 7 cloned receptors in cultured CHO cells to examine the intrinsic activity and the desensitization potential of different DA agonists at the human D2-family receptors, in vitro. Cloned receptor desensitization, change in GTPyS activation, and arachidonic acid release will be used to study the mechanisms of tolerance and desensitization operating here. These data will predict and later help us to select optimal agonist intrinsic activity ior clinical testing for antipsychotic actvity, duration of therapeutic action, and side effects.

The strategy of using partial dopamine (DA) agonists as antidopaminergic antipsychotic agents is based on two sets of observations: first, that DA neurons have autoreceptors which function to decrease DA synthesis, release and neuronal firing, and hence mediate antidopaminergic signals; and, second, that partial agonists have full affinity but reduced intrinsic activity at DA receptors, consequently they exert relatively lower receptor stimulation in competition with the natural neurotransmitter, dopamine. The investigators have suggested that antipsychotic treatment with partial DA agonists, compared to treatment with DA receptor antagonists may have significant clinical advantages. Efficacy and side effects of partial DA agonists will depend on the level intrinsic activity of the partial agonist, a range which can extend from less than 10 percent to over 90 percent. The investigators work to date (see Progress Report) suggests that a partial agonist activity somewhat below 40 percent may be optimal for schizophrenia. The investigators most useful partial DA agonist is (-)-3PPP. The strategy of combining a small proporb'on of a full antagonist (e.g. haloperidol or clozopine) with the partial agonist (-)-3PPP, to produce a functionally lower intrinsic activity of (-)-3PPP, adds flexibility to the clinical testing of the partial agonist strategy. The investigators first clinical study will focus on testing the antipsychotic action of a very low dose of haloperidol (0.5 haloperidol + (-)-3PPP (flexible dose range) or (-)3PPP placebo, compared to a third active control arm (5 mg bid haloperidol + (-)-3PPP placebo). Treatment in each of these three aims will be evaluated in the three primary symptom cluster of schizophrenia: 1) hallucinations/delusions; 2) disorganization, and 3) negative symptoms, and on cognitive function. Our second study will be designed exactly like the first study, except that a very low dose of clazopine will be utilized. Clazapine is low affinity tigand and may, in combination with (-)-3PPP, produce a better antipsychotic action based on its greater displacability. Because the investigators have already demonstrated significant efflcacy, but efflcacy to which tolerance occurs, the investigators current goal is to demonstrate that the efficacy of (-)-3PPP treatment, by modifying intrinsic activity and dosing schedules can be extended. If the investigators are able to overcome the efficacy tolerance, then one of these treatments would be ready for broader multicenter testing. Application of this strategy to other syndromes where neuroleptics improve psychosis is also indicated. In the biochemistry laboratory, we propose to use the D2', D4 2. D4 4 and D4 7 cloned receptors in cultured CHO cells to examine the intrinsic activity and the desensitization potential of different DA agonists at the human D2-family receptors, in vitro. Cloned receptor desensitization, change in GTPyS activation, and arachidonic acid release will be used to study the mechanisms of tolerance and desensitization operating here. These data will predict and later help us to select optimal agonist intrinsic activity ior clinical testing for antipsychotic actvity, duration of therapeutic action, and side effects.

DESCRIPTION: (provided by applicant) This application seeks to identify and characterize the nature and localization of anatomic and chemical abnormalities in the limbic cortex of schizophrenic (hippocampus, entorhinal cortex, and anterior cingulate) contributing to the pathophysiology of the disease. Several laboratories have generated data suggesting limbic pathology in schizophrenia; our own in vivo imaging and postmortem studies (see Prelim Data) suggest a limbic focus as well. Recently, data from Csernansky et al, have suggested that pathology in the hippocampus is not homogeneous, but is localized within that structure to the lateral head of the hippocampus and the medial aspect of the body (subiculum); this might explain the variability of outcomes reported across studies in postmortem analyses, because few studies control for hippocampal axis. To answer this question, we have paired anatomic and neurochemical measures within the hippocampus, entorhinal cortex, and anterior cingulate from anterior to posterior extent, quantifying markers of neuronal structure and transmission, which may be abnormal in schizophrenic limbic cortex. The hypothesis driving this work is based on our in vivo imaging data from patient studies and our animal model work, which are extensively in agreement with the published literature. We have raised the speculative hypothesis that positive symptoms in schizophrenia are associated with reduced glutamatergic activity at the NMDA receptor in the hippocampus. The resulting reduction in the activity of the glutamatergic hippocampal efferent signal to its projection fields, including entorhinal cortex, anterior thalamus, and anterior cingulate may underlie the generation of psychotic symptoms in schizophrenia. 24 postmortem schizophrenia brains with paired EC, hippocampi and cingulates will be compared to the same structures in 24 matched healthy and 12 matched psychotic control brains. We will study neuronal number, synaptic and dendritic density, along with neurochemical measures of the glutamate, and GABA, systems along the A-P- extent of these structures. We postulate that only certain regions of hippocampus will be affected (lateral head and medial body), and that the neurochemical abnormalities in these regions will colocalize with neuronal number and/or synaptic and dendritic changes, and that related regions of hippo, EC, and ACC will be affected. These data will have implications for understanding the mechanisms of the illness and for directing future new drug discovery for schizophrenia therapeutics.

DESCRIPTION (provided by applicant): This grant application proposes laboratory research projects to continue a productive line of research into the behavioral, neurochemical, and anatomic characterization of new antipsychotic drugs. The new generation of antipsychotic drugs has swept clinical markets around the world because of the full clinical actions of the compounds and their reduced motor side effect profiles. This project aims to compare the two most widely used antipsychotics (risperidone and olanzapine), and contrast them with a traditional drug (haloperidol) in a chronic animal treatment model with informative mouse behavior, neurochemical and anatomic assays. We will test effects of the two new antipsychotic drugs and haloperidol on two mouse behaviors when applied acutely and after 1,2,3, and 4 months of antipsychotic treatment: (1) PCP-disrupted prepulse inhibition (PPI) (purportedly modeling for attentional dysfunction in schizophrenia) and (2) PCP-disruption of social learning (purportedly modeling for learning dysfunction). Concurrently, we will analyze neurochemical and anatomic markers of neurotransmitter pathways in CNS, especially in those regions where clinical schizophrenia studies have localized attentional and cognitive dysfunction. The behavioral, neurochemical, and anatomic changes will be correlated over treatment time in each drug group and contrasted between drugs. These studies are a continuation of a productive approach aimed at studying antipsychotic drug actions using behavior (oral dyskinesias) to mark the drug action and regional neurochemical correlates to establish the putative mechanism (see Progress Report). We can expect that new antipsychotic drugs will have not only actions on positive symptoms but also display low motor side effects (acute and chronic) and ameliorate the short term memory and the attentional dysfunction of schizophrenia. Animal measures of these "new" actions could expedite drug development in this "new" broader and more complex direction. Concentration on mouse behaviors, neurochemistry and behavior will advance studies aimed at kinetic applications.

DESCRIPTION (provided by applicant): This grant application proposes laboratory research projects to continue a productive line of research into the behavioral, neurochemical, and anatomic characterization of new antipsychotic drugs. The new generation of antipsychotic drugs has swept clinical markets around the world because of the full clinical actions of the compounds and their reduced motor side effect profiles. This project aims to compare the two most widely used antipsychotics (risperidone and olanzapine), and contrast them with a traditional drug (haloperidol) in a chronic animal treatment model with informative mouse behavior, neurochemical and anatomic assays. We will test effects of the two new antipsychotic drugs and haloperidol on two mouse behaviors when applied acutely and after 1,2,3, and 4 months of antipsychotic treatment: (1) PCP-disrupted prepulse inhibition (PPI) (purportedly modeling for attentional dysfunction in schizophrenia) and (2) PCP-disruption of social learning (purportedly modeling for learning dysfunction). Concurrently, we will analyze neurochemical and anatomic markers of neurotransmitter pathways in CNS, especially in those regions where clinical schizophrenia studies have localized attentional and cognitive dysfunction. The behavioral, neurochemical, and anatomic changes will be correlated over treatment time in each drug group and contrasted between drugs. These studies are a continuation of a productive approach aimed at studying antipsychotic drug actions using behavior (oral dyskinesias) to mark the drug action and regional neurochemical correlates to establish the putative mechanism (see Progress Report). We can expect that new antipsychotic drugs will have not only actions on positive symptoms but also display low motor side effects (acute and chronic) and ameliorate the short term memory and the attentional dysfunction of schizophrenia. Animal measures of these "new" actions could expedite drug development in this "new" broader and more complex direction. Concentration on mouse behaviors, neurochemistry and behavior will advance studies aimed at kinetic applications.

DESCRIPTION (provided by applicant): The objective of the Psychiatry Research Education Program (PREP) is the training of general psychiatry residents in a broad range of clinical and basic science methods relevant to psychiatry. The program fills an important national need by increasing the number of clinical and basic science researchers in the mental health field, in particular, physician scientists in psychiatry. The goal is to produce academic psychiatrists who will pursue careers as clinical and basic researchers in the broad array of mental health areas. The University of Texas Southwestern Medical Center (UTSWMC) Department of Psychiatry Residency Training Program has conducted a research track for over 13 years. It is committed to establishing a continuum of training in psychiatric research, already having in place both outside and departmentally funded programs for pre-medical students, medical students, and post-residency fellows. However, because of funding limitations, the residency research track has been limited to approximately 9 months of research experience per resident. PREP will enable the residency to dramatically broaden its efforts to prepare trainees to develop into strong basic and clinical researchers in psychiatry. In addition, it will enable the resident research track to be broadened to permit the equivalent of 17 months of research training for each trainee. The UTSWMC Department of Psychiatry has long had a richness of resources in clinical mental health research that has attracted residents and medical students to it, and has more recently built an outstanding program in basic neuroscience. This includes strong linkages to other Basic Science Departments at UTSWMC. Together, these features place the UTSWMC Department of Psychiatry in an ideal position to stimulate and train the next generation of basic and clinical psychiatric researchers.

[unreadable] DESCRIPTION (provided by applicant): Persons with schizophrenia, despite receiving optimal doses of antipsychotic medications that reduce or entirely obliterate psychotic symptoms still fail to fully recover function. Research has shown that it is the cognitive dysfunction along with the negative symptoms that account for persistent psychosocial dysfunction. The field has recently taken on the task of identifying, testing, and developing new treatments for cognitive dysfunction in schizophrenia through the NIMH-sponsored MATRICS and TURNS projects (www.MATRICS.ucla.edu). The work of these groups is partially completed and they have defined for us (1) the nature of the cognitive dysfunction, (2) a battery of recommended neuropsychological tests to assess these cognitive features, and (3) likely molecular targets for cognitive enhancement (Psychopharmacology, June, 2004). Based on a considerable basic literature, we have been impressed that it may not only be a drug treatment (e.g., atomoxetine in this application) but also psychological approaches (e.g., cognitive remediation, in this application) that are needed to work together to optimally improve cognition in schizophrenia. Therefore, we have developed the hypothesis that the use of cognitive remediation in the context of a cognitive enhancing medication will be necessary for optimal cognitive improvement in schizophrenia. But, little direct preliminary data exist to suggest which drug and which cognitive approach may be effective, nor what the parameters of response to expect (e.g., effect size; response rate; attrition). Therefore, we are applying for a R34 grant to pilot the medication atomoxetine (to target one of MATRICS's highest-scored molecular targets: the D1 dopamine receptor in prefrontal cortex) along with a cognitive remediation routine (one that is already developed and has shown promise by itself in preliminary studies) for the treatment of cognitive dysfunction in schizophrenia. We will apply each putative treatment alone and combined, in a standard four cell design, and evaluate neuropsychological function as the primary outcome measure, and we will collect preliminary data on psychosocial improvements occurring with treatment, to determine its time course. [unreadable] [unreadable] [unreadable]

Our Center has recently launched a new initiative to study CREB and the other molecular targets of interest to Projects 1-4 in brain reward regions of depressed humans on autopsy. This work focuses primarily on the NAc (nucleus accumbens) and VTA (ventraltegmental area). This endeavor represents a new Project 5 for the Center in this competitive renewal. We have already begun the collection of brains from depressed humans via the Dallas Brain Collection. Such collections have been proceeding at a rapid pace, which ensures the availability of an adequately large enough sample for meaningful analysis. The Project offers several powerful features for Center research. 1) We utilize the most stringent and rigorous measures of brain tissue quality, which is essential for postmortem brain studies. 2) Our focus on human brain reward regions complements most current efforts in the field, which have largely analyzed other brain circuits. 3) By focusing on the same genes and proteins that preclinical investigators study in rodent models of depression, the Project provides a major driving force for the critical translational mission of our Center. 4) We will examine these molecular targets both as a function of a diagnosis of depression (i.e., as seen in patients with major depression) and as a function of symptoms of depression (i.e., as seen across several diagnoses, including major depression, bipolar depression, and schizoaffective disorder with depression). 5) Alterations in molecular targets in the VTA and NAc will also be characterized as a function of developmental risk factors for depression (based on extensive history of the human subjects) and of particular genotypes recently implicated in genetic risk for depression. 6) The Project will study the possible influence of long-term antidepressant treatment on these molecular targets by treating rodents with prototypical agents for 6 months. We are very excited by the potential of this new initiative. We have demonstrated the feasibility of studying the various gene products of interest in human postmortem NAc and have already documented abnormalities in some of these products, which we know are altered in rodent depression models. At the same time, findings from the human tissue have provided new insight into regulation of these molecular pathways, which is guiding the preclinical research in the other Projects. Moreover, we have established the capability of carrying out advanced molecular analyses on human postmortem tissue, including, well beyond traditional DNA expression arrays, chromatin immunoprecipitation (ChIP), ChIP on chip, and microRNA assays in conjunction with the Chromatin and Gene Regulation Core. Together, the proposed studies will provide a uniquely powerful analysis of molecular pathologies in the human VTA-NAc associated with depression and its treatment.

DESCRIPTION (provided by applicant): This grant application proposes laboratory research projects to continue a productive line of research into the behavioral, neurochemical, and anatomic characterization of new antipsychotic drugs. The new generation of antipsychotic drugs has swept clinical markets around the world because of the full clinical actions of the compounds and their reduced motor side effect profiles. This project aims to compare the two most widely used antipsychotics (risperidone and olanzapine), and contrast them with a traditional drug (haloperidol) in a chronic animal treatment model with informative mouse behavior, neurochemical and anatomic assays. We will test effects of the two new antipsychotic drugs and haloperidol on two mouse behaviors when applied acutely and after 1,2,3, and 4 months of antipsychotic treatment: (1) PCP-disrupted prepulse inhibition (PPI) (purportedly modeling for attentional dysfunction in schizophrenia) and (2) PCP-disruption of social learning (purportedly modeling for learning dysfunction). Concurrently, we will analyze neurochemical and anatomic markers of neurotransmitter pathways in CNS, especially in those regions where clinical schizophrenia studies have localized attentional and cognitive dysfunction. The behavioral, neurochemical, and anatomic changes will be correlated over treatment time in each drug group and contrasted between drugs. These studies are a continuation of a productive approach aimed at studying antipsychotic drug actions using behavior (oral dyskinesias) to mark the drug action and regional neurochemical correlates to establish the putative mechanism (see Progress Report). We can expect that new antipsychotic drugs will have not only actions on positive symptoms but also display low motor side effects (acute and chronic) and ameliorate the short term memory and the attentional dysfunction of schizophrenia. Animal measures of these "new" actions could expedite drug development in this "new" broader and more complex direction. Concentration on mouse behaviors, neurochemistry and behavior will advance studies aimed at kinetic applications.

DESCRIPTION (provided by applicant): Recent studies provide considerable evidence that schizophrenia (SZ) and psychotic bipolar disorder (BP) may share overlapping etiologic determinants. Identifying disease-related genetic effects is a major focus in SZ and BP research, with enormous implications for diagnosis and treatment for these two disorders. Efforts have been multifaceted, with the ultimate goal of describing causal paths from specific genetic variants, to changes in neuronal functioning, to altered brain anatomy, to behavioral and functional impairments. Parallel efforts have identified and refined several alternative endophenotypes that are stable, heritable, have (partly) known biological substrates, and are associated with psychosis liability. Although many such endophenotypes have been individually studied in SZ, and to a lesser extent in BP, no study has comprehensively assessed a broad panel of these markers in the two disorders with parallel recruitment, and the extent to which they mark independent aspects of psychosis risk, or their overlap in the two disorders. This line of investigation will potentially impact our conceptualization of psychotic disorders, help us make critical strides to identify the pathophysiology of psychosis, and guide development of new specific treatments targeting particular deficits. The overall goal of the proposed research is to examine a broad panel of putative endophenotypes in affected individuals with schizophrenia and bipolar and their unaffected relatives in order to: 1) characterize the degree of familial phenotypic overlap between SZ and psychotic BP;2) identify patterns of endophenotypes unique to the two disorders, and 3) contrast the heritability of endophenotypes across the disorders. To achieve these goals, we will recruit 500 SZ and 500 BP I (with psychosis) probands, ~1700-2000 1st degree relatives of these probands, and 500 unrelated non-psychiatric controls from five centers. We will obtain measures of neurophysiology (e.g., eye tracking, P50 gating, PPI, and P300), neurocognition (e.g., attention/vigilance, episodic and working memory), and brain structure (e.g., volumes of gray and white matter in specified brain regions). We will collect blood for future genetic studies. We will assess the degree of familial aggregation of endophenotypes in SZ and BP relatives. Establishing similarities and differences in the endophenotypic signatures within SZ and BP families will provide important insights for future genetic studies, and clarify concepts about common and distinct aspects of pathophysiology, potentially meaningful heterogeneity within disorders, and the clinical boundaries of the two commonest psychotic disorders in adult psychiatry. This research will be conducted by 5 experienced research groups, with a long history of close and productive collaboration. Public Health Relevance: This multisite project will identify endophenotypes (or liability markers) that are shared and different in schizophrenia and bipolar disorder. Findings from these studies will provide important insights for future genetic studies, and clarify concepts about common and distinct aspects of pathophysiology, potentially meaningful heterogeneity within disorders, and the clinical boundaries of the two commonest psychotic disorders in adult psychiatry.

DESCRIPTION (provided by applicant): The Basic Science Training Program in the Neurobiology of Mental Illness (NMI) at UT Southwestern is designed to provide interdisciplinary, basic disease-oriented research training directly relevant to mental illness to predoctoral and postdoctoral fellows. This application for continued support for our NMI Training Program at UT Southwestern is a direct response to NIMH's call for more basic scientists trained in a broad range of diverse, innovative basic research that closely informs our understanding and treatment of mental illness. In addition to the paucity of basic science researchers nationwide exploring the neurobiology of neuropsychiatric diseases, there is, conversely, a dearth of clinically-trained individuals pursuing basic research in mental illness, thus diminishing the very cross talk that is urgently needed in this field. The complexity of mental disorders demands an interdisciplinary approach to illuminate underlying disease mechanisms and to develop better diagnostic measures, treatments, and ultimately cures. Our NMI training program has numerous strengths, including: a) the outstanding environment at UT Southwestern in which to conduct basic, interdisciplinary biomedical research; b) the intellectual intensity and close-knit nature of the UT Southwestern neuroscience community; c) the integration of fundamental neurobiological research performed in multiple academic divisions; d) the unusually strong foundation at UT Southwestern to explore fundamental underpinnings of depression, schizophrenia and autism; e) the preexisting integration of basic science with clinical programs in mental illness; f) the breadth and depth of our potential trainees; g) calculated interactions between junior and senior mentors, thus ensuring that junior mentors will also benefit from the Training Program and will remain in mental health research in future years; and h) novel, translationally-oriented training components, such as hands-on neurophysiology and human neuroanatomy laboratories, a new Clinical Correlations Seminar, and the presence of a clinician on each trainee's doctoral thesis committee.

DESCRIPTION (provided by applicant): Alterations in the function of the medial temporal lobe (MTL) have been described in schizophrenia (SZ). The MTL shows elevated basal perfusion and decreases in task-stimulated activations in SZ, especially in the anterior MTL. The examination of these MTL changes in SZ will be challenging because antipsychotic drugs (APD) - used to treat almost all people with the illness - attenuate these behavioral and functional alterations;therefore, the studies here proposed will necessarily involve untreated (SZ-off) as well as treated (SZ-on) volunteers with schizophrenia. Now is an optimal time to characterize these MTL functions in schizophrenia because of the sophisticated research tools available to determine regional neuronal activity in brain, the rich advances in cognitive neuroscience, and the focus of SZ research on cognition. It is a propitious time to examine mechanisms associated with hippocampal dysfunction in schizophrenia given the multiple efforts to develop treatments for cognition, treatments that may affect the MTL. Examination of the MTL abnormalities in SZ as described in this proposal will require assessment of both perfusion and task-stimulated activity, since both appear altered, may interact with each other and may be differentially reflected in two of the SZ symptom domains, psychosis and cognition. Current imaging methods allow for a standard- and a high-resolution examination of MTL, so we will pursue both the standard-resolution whole brain approach to test which CNS areas overall are altered during declarative memory tasks in SZ along with the MTL, as well as the high- resolution (high-res), focused method to test which subfields of hippocampus are altered in SZ and to associate these changes with symptoms of the illness. Under both conditions, we will examine the effect of APD treatment on perfusion and activation. One of the ultimate goals in exploring the effects of APD on MTL memory function in schizophrenia is the promise of discovering a more direct, possibly more efficient, pharmacological approach for correcting altered MTL-associated symptoms in the illness. This proposal suggests, not that the MTL is the only region associated with pathology in SZ, but rather that it is a critical player in the overall expression of psychopathology and a good model region in which to examine a new formulation for symptoms. What we propose in this application is to examine memory performance and MTL function in SZ to determine the nature, extent, and circumstances of the changes in MTL neuronal activity in schizophrenia. This project represents a close collaboration between two laboratories, one focused on schizophrenia studies (Tamminga at UTSW) and the other on human memory mechanisms (Wagner at Stanford), together attempting to translate basic cognitive neuroscience to the understanding of symptom domains in SZ. Although this proposal includes only the experiments in SZ, it is based on extensive collaboration between the two sites, involving interactions around concepts and paradigms, shared methodology, and analytic approaches. PUBLIC HEALTH RELEVANCE: Schizophrenia is an illness without known pathophysiology or etiology. However, defining domains of symptomatology, namely, psychosis and cognitive dysfunction, has allowed the formulation of a new model for the illness. This formulation includes recent discoveries from molecular and functional neuroscience and suggests that one primary lesion (associated with the cognitive dysfunction) sets up an altered metaplasticity process in downstream tissue targets, which is then associated with psychosis. We propose to test the elements of this model with in vivo brain imaging using measures of basal activity and relational memory probes, correlating alterations in neural activity with characteristics of the illness.

DESCRIPTION (provided by applicant): Recent studies provide considerable evidence that schizophrenia (SZ) and psychotic bipolar disorder (BP) may share overlapping etiologic determinants. Identifying disease-related genetic effects is a major focus in SZ and BP research, with enormous implications for diagnosis and treatment for these two disorders. Efforts have been multifaceted, with the ultimate goal of describing causal paths from specific genetic variants, to changes in neuronal functioning, to altered brain anatomy, to behavioral and functional impairments. Parallel efforts have identified and refined several alternative endophenotypes that are stable, heritable, have (partly) known biological substrates, and are associated with psychosis liability. Although many such endophenotypes have been individually studied in SZ, and to a lesser extent in BP, no study has comprehensively assessed a broad panel of these markers in the two disorders with parallel recruitment, and the extent to which they mark independent aspects of psychosis risk, or their overlap in the two disorders. This line of investigation will potentially impact our conceptualization of psychotic disorders, help us make critical strides to identify the pathophysiology of psychosis, and guide development of new specific treatments targeting particular deficits. The overall goal of the proposed research is to examine a broad panel of putative endophenotypes in affected individuals with schizophrenia and bipolar and their unaffected relatives in order to: 1) characterize the degree of familial phenotypic overlap between SZ and psychotic BP; 2) identify patterns of endophenotypes unique to the two disorders, and 3) contrast the heritability of endophenotypes across the disorders. To achieve these goals, we will recruit 500 SZ and 500 BP I (with psychosis) probands, ~1700-2000 1st degree relatives of these probands, and 500 unrelated non-psychiatric controls from five centers. We will obtain measures of neurophysiology (e.g., eye tracking, P50 gating, PPI, and P300), neurocognition (e.g., attention/vigilance, episodic and working memory), and brain structure (e.g., volumes of gray and white matter in specified brain regions). We will collect blood for future genetic studies. We will assess the degree of familial aggregation of endophenotypes in SZ and BP relatives. Establishing similarities and differences in the endophenotypic signatures within SZ and BP families will provide important insights for future genetic studies, and clarify concepts about common and distinct aspects of pathophysiology, potentially meaningful heterogeneity within disorders, and the clinical boundaries of the two commonest psychotic disorders in adult psychiatry. This research will be conducted by 5 experienced research groups, with a long history of close and productive collaboration. Public Health Relevance: This multisite project will identify endophenotypes (or liability markers) that are shared and different in schizophrenia and bipolar disorder. Findings from these studies will provide important insights for future genetic studies, and clarify concepts about common and distinct aspects of pathophysiology, potentially meaningful heterogeneity within disorders, and the clinical boundaries of the two commonest psychotic disorders in adult psychiatry.

PROJECT SUMMARY ? PROJECT 4 (UT SOUTHWESTERN AND MOUNT SINAI) Over the past four years, Project 4 has made robust progress in defining gene expression and associated chromatin abnormalities that occur in specific limbic brain regions of depressed humans. Working with Projects 1 through 3, we validated numerous findings from mouse models in human depression, which ensures that the other Projects remain focused on mechanisms relevant to the human syndrome. In parallel, we defined novel transcriptional and epigenetic abnormalities in the depressed human brain. A major milestone is completing RNA-seq of six brain regions from ~100 subjects?half depressed, half control; half male, half female. While the data revealed many genes similarly affected in depressed men and depressed women, striking sex differences were observed as well, suggesting that depression may be a fundamentally distinct syndrome in the two sexes. This dataset helped define the current focus of the other Projects. It also provides the foundation for our proposed experiments. We will extend RNA-seq analysis to an additional cohort of 100 subjects, which is necessary given the heterogeneity of the depression syndrome. We will complement this work with ChIP-seq and, with Projects 2 and 3 by mapping the 3D genome and nucleosome turnover, to begin to define genome-wide the epigenetic mechanisms controlling the aberrant gene expression seen in human depression. We will focus on key target genes identified in these studies as being altered in a sex-specific manner in either prefrontal cortex (PFC) or nucleus accumbens (NAc) in human depression, regulation since replicated in mouse models. Among the regulated genes are those that encode several long-noncoding RNAs for which homologues do not exist in rodents?emphasizing the importance of gene discovery in human brain. As well, we will relate gene and chromatin changes to demographic features of the cases and controls, examining the effect of early life stress and moving beyond syndromal depression to key domains of behavioral abnormalities. We also will continue to build our bank of depressed and control human brains. The work of Project 4 thus embodies the bidirectional translation that defines this Center and its promise of discovering new mechanisms for the pathophysiology of depression and other stress-related illnesses.

DESCRIPTION (provided by applicant): Psychotic symptoms are present in a significant subset of individuals with Bipolar Disorder (BD) and carry devastating personal and clinical implications. Most biomedical research on BD has ignored the variable presentation of psychosis possibly overlooking biologically significant heterogeneity in BD; such heterogeneity may cause inconsistencies in the literature by treating BD as a homogenous category 7,18. The expression of psychosis in some BD patients (BD-P) and absence in others (BD-NP) may indicate divergent disease processes of critical nosological and clinical relevance. PARDIP leverages a large sample of BD, a comprehensive battery, and sophisticated analytic tools to establish whether BD-P and BD-NP represent a difference in degree or a difference in kind. Long-term goals: This work will critically impact how BD is classified and studied, provide robust targets for effective future etiological studies, and clarify the utility of available biomarkers o major psychiatric disturbance. PARDIP represents a step toward mechanistically based classification of psychiatric disorders. Specific Aims: PARDIP will (i) identify the patterns of bo-cognitive disruptions which mark psychosis (BD-P`BD-NP) or mood instability in general (BD`healthy comparisons), (ii) explore how these biomarkers relate to one another and to other dimensions of psychopathology present in BD, and (iii) utilize latent class and cluster analyses of the multivariate dataset to verify taxonicity within BD with regard to psychosis and uncover latent psychiatric subgroups of interest for future genotyping and etiological research. Methods: The three-year PARDIP project will recruit 135 psychotic BD, 135 non-psychotic BD, and 135 psychiatrically healthy comparison subjects (all new recruits), administering a comprehensive battery focused on the psychosis and mania domains of psychopathology. We will obtain measures of neurophysiology, (smooth pursuit eye movements, antisaccades, auditory ERPs), cognition (cognitive battery, response inhibition, spatial working memory), neuroanatomy (structural magnetic resonance imaging [MRI]), emotional processing (ERPs to emotional pictures), intrinsic brain state (resting functional MRI connectivity), and circadian function (Actigraphy). We will compare biomarkers between BD-P, BD-NP, and H groups to determine which track with psychosis and which track with affective disturbance. We will identify common sources of variance among measures with joint-ICA and PCA approaches, and examine how biomarkers and biomarker composites relate to other aspects of clinical heterogeneity. Taxometric procedures (MAXCOV- HITMAX and its multivariate extension MAXEIG-HITMAX and k-means clustering) will be carried out with the multivariate dataset to empirically identify distinct subgroups of subjects. PARDIP will be conducted by 4 experienced research groups (across 3 collection sites) with a long history of close and productive collaboration.

DESCRIPTION (provided by applicant): The major psychoses (SZ, SAD, BDP), when defined by clinical phenomenology alone, overlap extensively on neurobiological, biomarker, co-morbid, symptomatic, and genetic characteristics. Our field may benefit from transformational re-conceptualizations of disease seen in other areas of medicine when biological variables are considered in disease definitions and identification. This approach in psychiatry will depend on: (i) use of well- defined disease domains, (ii) large samples that capture clinical heterogeneity and support statistical approaches, and (iii) ability to acquire quantifiable laboratory measures t inform re-conceptualization of disease characteristics. The 5-site B-SNIP focus is psychosis, an ideal clinical phenotype for this purpose. B- SNIP1 recruited over 2500 volunteers and performed dense phenotyping across multiple levels of analysis (cognitive, psychophysiological, brain imaging, social and clinical). The overall data described a continuum of phenotypic alterations across the DSM psychosis diagnoses (BDP, SAD, SZ) with little evidence of diagnostic specificity. In an attempt to use these dense phenotypic characteristics to define biologically based subgroups, we re-grouped probands using biomarkers and a multistage multivariate analysis procedure. We identified 3 psychosis Biotypes based on core phenotypic features. Biotypes showed unique differences across external validators that were not used in the initial construction of the categories. B-SNIP2 will replicate and extend B- SNIP1 using enhanced proband number, biomarker panel, and sophistication of multivariate statistical approaches. We will accomplish our goals within the context of two specific aims. SA(1) Construct a 'Psychosis Biomarker Database' (PBD): Recruit 3000 new psychosis probands and 600 healthy volunteers and collect data including clinical, psychosocial, electrophysiological, ocular motor, imaging and blood biomarkers. Core biomarkers (used for Biotype definition) and external validators (used for verifying neurobiological distinctiveness of Biotypes) will be collected as specified. Genetic characteristics of the participants will be obtained in collaboratin with the Broad Institute. SA(2) Contrast and test taxometric approaches to categorizing psychosis: Evaluate the ability of different taxonomic structures to define psychosis subgroups, based on data in the PBD: (i) DSM, (ii) B-SNIP2 biotypes based on clinical variables, (iii) B-SNIP1 Biotypes, (iv) B-SNIP2-generated biotypes based on biomarkers, and (v) B-SNIP2 biotypes based on both clinical variables and biomarkers. Beginning with traditional DSM diagnostic criteria as the taxonomy and testing (i)-(v) we will use linear, quadratic and nonparametric discriminant function analysis applied to external biomarker validators to examine the association between the traditional diagnostic system and the biologically- derived classification (imaging, psychosocial and genetic external validators). We will be able to determine the strongest taxonomic approach based on biological characteristics. We seek a rational classification of psychotic disorders that will be successful in identifying novel disease targets and treatments approaches.

ABSTRACT The hippocampus has been implicated in numerous functions related to normal memory and its dysfunction in several diseases. Our lab has investigated the hippocampus in relation to schizophrenia (SZ) pathophysiology using cognitive and behavioral outcomes(1-3) and brain image analyses(4-6). These consistently show that hippocampal (Hipp) activity is elevated in schizophrenic psychosis (SZ), especially in early illness. To test the molecular basis of this hyperactivity, we examined human postmortem hippocampal tissue by subfield, contrasting healthy and schizophrenia cases, using excitatory and inhibitory synaptic markers and Golgi. We found a reduction in GluN1 limited to dentate gyrus (DG) and an increase in markers of synaptic strength in CA3 in the SZ tissue; these changes are consistent with the observations that Lee et al(7) reported in hippocampal cell cultures (see A.1). Lee showed that CA3 pyramidal cell sensitivity is inversely and powerfully controlled by afferent input from DG, with decreased afferent input associated with increased pyramidal cell activity. We have been able to recapitulate this human-specific SZ pathology in a mouse using a DG-selective GluN1 knock out (KO)(8). This back-translation mouse KO demonstrated Hipp hyperactivity and alterations in Hipp-mediated behaviors (8). We are piloting an inhibitory DREADD technique in DG to mimic the DG-selective GluN1 KO mouse and saw evidence of a sensitive period during ?adolescence?, when reduced DG activity could stimulate hyperactivity in CA3/CA1. This time phase cannot be resolved in the KO animal, so we had not seen it before and can only study it using DREADDs. The goal of these experiments are to causally define the mechanisms underlying the neurobiological outcomes of temporary DG hypofunction in mouse using DREADD constructs, and to show the extent, development, and critical periods of vulnerability of brain-wide changes. Having found a discrete circuit of Hipp projection regions hyperactive in the KO mouse, we will test human SZ vs HC tissue in these regions for evidence of hyperactivity and coherence with Hipp. The goal is to build a model of how hippocampal hyperactivity affects behavior and brain pathology, and specifically how this tissue pathology could support aberrant memories with psychotic content.

Project Summary Treatment advances in psychosis may be limited by the use of phenomenology-defined diagnoses based on symptomatic outcomes, rather than by neurobiological constructs monitored by quantitative characteristics. The Bipolar-Schizophrenia Network for Intermediate Phenotypes (B-SNIP) uses biomarkers to define psychosis subgroups with the goal of testing the advantages of B-SNIP biomarkers for diagnostic and therapeutic decisions, consistent with principles in the NIMH Strategic Plan (NSP). With >3000 phenotyped psychosis probands, relatives and healthy controls, B-SNIP has a multilevel biomarker library for psychosis and used that library to re-conceptualize psychosis subgroups as biomarker-defined Biotypes (B1, B2, B3), where B1 and B2 are the low cognition/high symptom groups and B3 shows lower symptoms and relatively normal cognition. We replicated Biotypes in a new sample, ?forging a future where measures of an individual?s ? neural and physiological state will form the basis of an increasingly specific and informative diagnosis? (NSP). In this grant we propose that B1, with its low cognition and low cortical activity, will respond uniquely to clozapine, a drug which will generate active cortical attractor networks in B1 to support symptomatic improvement. Clozapine is the most effective antipsychotic drug (APD) with unique clinical efficacy. It is the least used APD because its side effects are serious (neutropenia, myocarditis, seizures) and its administration complex. A predictive biomarker would allow targeting of cases most likely to respond and improve prognosis in psychosis. B-SNIP has shown that clozapine is associated with increases in EEG measures of alpha/theta power, and we identify this increase in time periods without stimulus processing requirements as intrinsic EEG activity (IEA), across all Biotypes. Because B1 cases express low IEA, clozapine?s action to increase EEG power will be normalizing for this psychosis subgroup, with increased cortical attractor states. Because B2 express accentuated IEA, clozapine is associated with more deviant IEA in B2. We propose to test B1 psychosis cases with clozapine vs. risperidone (n=40/group clinical trial completers), over a 6 week cross-titration (to therapeutic plasma levels) and a 9 week stable dose extension, predicting that the B1/clozapine group will respond significantly better, as measured with total PANSS, than the B1/risperidone group and also better than either B2 group. It is our hypothesis that the cortical attractor networks will be normalized and their function increased by the increase in intrinsic EEG activity.