American Journal of Medical Genetics (Neuropsychiatric Genetics) 67:468-472 (1996)
Association of Codon 108/158
Catechol-0-Methyltransferase Gene Polymorphism
With the Psychiatric Manifestations
of Velo-Cardio-Facial Syndrome
Herbert M. Lachman, Bernice Morrow, Robert Shprintzen, Sabine Veit, Sam S. Parsia,
Gianni Faedda, Rosalie Goldberg, Raju Kucherlapati, and Demitri F. Papolos
Departments of Medicine (H.M.L.), Psychiatry (H.M.L., D.F.P., S.V., G.F.), Molecular Genetics (R.K., B.M., R.G.),
Pediatrics (R.G.), Otolaryngology (R.S.), and Plastic Surgery (R.S., R.G.), Albert Einstein College of Medicine (S.S.P.),
Bronx, New York
mon congenital disorder associated with
typical facial appearance, cleft palate, car-
diac defects, and learning disabilities. The
majority of patients have an interstitial
deletion on chromosome 22qll. In addition
to physical abnormalities, a variety of psy-
chiatric illnesses have been reported in pa-
tients with VCFS, including schizophrenia,
bipolar disorder, and attention deficit hy-
peractivity disorder. The psychiatric mani-
festations of VCFS could be due to haploin-
sufficiency of a gene(s) within 22qll. One
candidate that has been mapped to this re-
gion is catechol-0-methyltransferase (COMT).
W e recently identified a polymorphism in
the COMT gene that leads to a valine-me-
thionine substitution at amino acid 158 of
the membrane-bound form of the enzyme.
Homozygosity for COMT158met leads to a 3-4-
fold reduction in enzymatic activity, com-
pared with homozygotes for COMT158'"'. W e
now report that in a population of patients
with VCFS, there is an apparent association
between the low-activity allele, COMT15€imet,
and the development of bipolar spectrum
disorder, and in particular, a rapid-cycling
1996 Wiley-Liss, Inc.
(VCFS) is a com-
Received for publication January 22, 1996; revision received
Address reprint requests to Herbert M. Lachman, Department
of Medicine, Albert Einstein College of Medicine, 1300 Morris
Park Ave, Bronx, NY 10461.
1996 Wiley-Liss, Inc.
KEY WORDS: bipolar disorder, rapid cycling,
Although a number of Mendelian traits have been
mapped by linkage analysis, it has been difficult to map
vulnerability genes for complex psychiatric conditions
such as bipolar affective disorder (BPD) and schizo-
phrenia. One way to learn more about the underlying
molecular and genetic basis of psychiatric illnesses,
and perhaps identify potential candidate genes for
analysis, is to characterize chromosomal alterations in
conditions that are associated with psychiatric mani-
festations. A good example is velo-cardio-facial syn-
drome (VCFS), a congenital disorder that results in
typical facial appearance, cleft palate, cardiac defects,
and learning disabilities [Shprintzen et al., 1978;
Scambler et al., 1992; Halford et al., 1993; Morrow
et al., 19951. Approximately 80-85% of patients with
VCFS have an interstitial deletion on chromosome
22qll that is at least 1-2 megabases [Scambler et al.,
1992; Halford et al., 1993; Lindsay et al., 1995; Morrow
et al., 19951.
In addition to physical anomalies, a variety of psy-
chiatric illnesses have been reported in patients
with VCFS, including schizophrenia, attention deficit
hyperactivity disorder (ADHD), separation anxiety dis-
order, obsessive-compulsive disorder (OCD), and BPD
[Shprintzen et al., 1992; Goldberg et al., 1993; Chow
et al., 1994; Pulver et al., 1994; Papolos et al., 19951. In
a recent evaluation, Papolos et al., [19951 studied 20
children and early adolescents with VCFS and found an
unexpectedly high percentage (70%) with bipolar spec-
It is very likely that the psychiatric manifestations of
VCFS result from the deletion of one or more genes on
22qll. One potential candidate gene found in this re-
Association of COMT With VCFS
reached. Only one patient (AP1079) was not seen by us.
She was diagnosed on the basis of a semistructured in-
terview conducted with a parent and a review of the
clinical history with her psychiatrist.
The controls used in this study were Caucasian
North Americans (46 males, 43 females) with no per-
sonal or family history of bipolar disorder or schizo-
Codon 108/158 Polymorphism
Genotype was determined, blind to psychiatric diag-
nosis, by PCR-RFLP analysis, as described in detail
in Lachman et al. . Briefly, a 210-base pair
PCR product was generated using the primers 5'-CT-
CATCACCATCGAGATCAA and 5'-GATGACCCTGG-
TGATAGTGG (nucleotides 1881-1900 and 2071-2090,
GenBank accession number 226491 [Bertocci et al.,
1991; Lundstrom et al., 1991; Tenhunen et al, 19941).
The PCR product (10 pl) was treated with 5 units of
Nla 111 for 3 hr at 37°C and separated by electrophore-
sis through an 8% nondenaturing acrylamide gel.
Statistical analysis was performed using an Instat
(Graphpad Software, San Diego, CA) statistical pro-
gram. A one-tailed Fisher's exact test was applied.
An association study was carried out to determine
the frequency of COMT158"et in psychiatrically af-
fected VCFS patients. The population studied is an ex-
tension of the group previously ascertained for psychi-
atric illness by molecular genetic analysis [Morrow
et al., 1995; Papolos et al., 19951. The single African
American individual (AP1088) from the original study
was omitted in this association study because substan-
tial racial differences in the frequency of COMT158"et
have been detected (Lachman, unpublished observa-
tions). Of the 25 patients with VCFS in this study, 23
had detectable deletions within 22qll [Lindsay et al.,
1995; Morrow et al., 19951. Two patients (BM102 and
BM26) have the typical stigmata of VCFS, but a large
22qll deletion could not be detected. At least one DSM-
111-R diagnosis was found in 23/25 patients (Table I).
The high incidence of psychiatric illness in this group,
compared with that previously reported in VCFS, may
be due in part to ascertainment bias, since a few pa-
tients previously diagnosed with psychiatric illness
were asked to participate in the study. In addition, pa-
tients with psychiatric symptoms may have been more
willing to cooperate and undergo a rigorous psychiatric
diagnostic interview. There were 17 patients with
bipolar spectrum disorder (BPI, BPII, cyclothymia,
schizoaffective-manic subype), 1 1 with attention deficit
disorder (ADD) or ADHD, 5 of whom were comorbid for
either BPD or cyclothymia, and 2 with OCD. Interest-
ingly, 7 patients with BPD were found to have a rapid-
cycling variant. Although this is defined by DSM-111-R
as four or more cycles a year, all of the rapidly-cycling
patients in this group experienced more frequent
episodes, approximately 8-10 a year.
The observed frequency of COMT158met was compared
with the expected frequency based on 174 chromosomes
from Caucasian controls (COMT158"et = 0.402 and
gion is catechol-0-methyltransferase (COMT, EC
220.127.116.11) [Scambler et al., 1992; Grossman et al., 19921.
COMT inactivates catecholamines and catechol-containing
drugs by catalyzing S-adenosyl-L-methionine-dependent
methyl conjugation [Axelrod and Tomchick, 19581. Be-
cause of its role in catecholamine metabolism, COMT
enzymatic activity has previously been measured in the
peripheral blood of patients with mood disorders and
schizophrenia. However, the results of these studies
have been equivocal [Dunner et al., 1977; Philippu
et al., 1981; Puzynski et al., 1983; Karege et al., 19871.
COMT enzymatic activity is subject to substantial
variability in humans. Approximately 20-25% of Cau-
casians have been found to express a heat-labile, low-
activity enzyme, whereas a somewhat higher percent-
age express a high-activity enzyme that is heat-stable
[Weinshilboum and Raymond, 1977; Scanlon et al., 1979;
Spielman and Weinshilboum, 1981; Boudikova et al.,
1990; Aksoy et al., 19931. We and others have recently
established that low activity and heat lability are pri-
marily due to a G+A transition at codon 158 of the
gene encoding the membrane-bound form of the en-
zyme (MB-COMT), which corresponds to codon 108 of
the soluble form (S-COMT), leading to a valine+
methionine substitution [Lotta et al., 1995; Lachman
et al., 19961.
Since dopamine has been postulated to play a role in
the pathogenesis of BPD, schizophrenia, and ADHD
[Diehl and Gershon, 1992; Kahn and Davis, 1995; Cook
et al., 19951, and since dopamine is inactivated by
COMT, we reasoned that hemizygosity for the low-
activity allele, COMT158met, could be a factor in the
emergence of psychiatric symptoms in VCFS.
MATERIALS AND METHODS
Patients with VCFS presented with typical mild fa-
cial dysmorphology, cleft palate, cardiac defects, and
learning disabilities. The ethnic makeup of the patients
included 18 Caucasians of mixed North American heri-
tage, 5 European Caucasians, and 3 Hispanics. Micro-
deletions were detected by FISH analysis and by the
loss of heterozygosity for informative 22qll dinucleo-
tide markers, as previously described [Lindsay et al.,
1995; Morrow et al., 19951. The Diagnostic Interview
for Children and Adolescents-Parents and Child Versions-
Revised (DICA-R, DICA-RC) [Herjanic and Campbell,
1979; Herjanic and Reich, 1982; Reich et a1.,1995] were
used to elicit symptoms of childhood psychiatric disor-
ders. Patients above age 18 were administered a com-
puterized version of the Standardized Clinical Diag-
nostic Interview (SCID) for DSM-111-R. For the adult
patients, when possible, a parent DICA-R was also
obtained. A semistructured clinical interview with
patient and parents was administered by a research
psychiatrist to validate and elucidate the specific symp-
toms reported by the DICA-R and SCID interviews.
Two research psychiatrists used these data, as well as
a review of all available medical and psychiatric
records, to establish a DSM-111-R diagnosis. If a con-
sensus diagnosis could not be made, a meeting was held
where the case was discussed and a consensus was
Lachman et al.
TABLE I. Psychiatric Diagnosis and COMT 108/158 Polymorphism*
1 2 s
2 0 m
ADHD, avoidance disorder
ADD, past major depression
BPII (rapid cycling),
BPII (rapid cycling),
BPII (rapid cycling)
BPII (rapid cycling)
BPII (rapid cvclind
BPI (radid cyclingj
BPI (rapid cycling), OCD
*BPI, bipolar I disorder; BPII, bipolar I1 disorder; ADHD, attention deficit hyperactiv-
ity disorder; ADD, attention deficit disorder without hyperactivity; OCD, obsessive-
compulsive disorder; ODD, oppositional defiant disorder; SP, simple phobia.
COMT158"a' = 0.598, Table 11). This is similar to the
value established in an analysis of enzyme activity con-
ducted on 900 red blood cell samples [Spielman and
Weinshilboum, 19811. Since association studies can be
significantly affected by population differences in allele
frequencies, we also genotyped the available parents of
the psychiatrically affected VCFS patients (N = 21 in-
dividuals, 9 sets of 2 parents, 3 single parents). This
analysis actually revealed a somewhat lower frequency
of COMT158met (0.357) than that found in controls
(Table 11). However, since more than half of the parents
were unavailable for analysis, we chose the more con-
servative estimate of 0.402 for this association study.
As shown in Table 111, the frequency of COMT158met
is increased, ranging between 0.64-1.00 under the dif-
ferent diagnostic categories. Statistical significance
was just reached in subgroups of bipolar spectrum dis-
order that included cyclothymia in the diagnostic
scheme. However, the most significant finding occurred
in the subgroup of patients who were diagnosed with
rapid-cycling BPD. All eight COMT alleles, derived
from 7 individuals with 22qll deletions and one with
nondeletion VCFS, were COMT158"'et (P = 0.013). This
association is not due to an increase in COMT158"et oc-
curring in VCFS. An analysis of 40 chromosomes from
37 anonymous VCFS patients not known to have psy-
chiatric illness (34 with 22qll deletion, 3 nondeletion)
revealed a frequency of 0.425 (data not shown).
The primary psychiatric diagnoses found in the pop-
ulation of patients with VCFS described in this report
were BPD and ADHD. The increased frequency of mood
disorder contrasts with a report showing a relatively
high incidence of schizophrenia in VCFS [Pulver et al.,
19941. However, some patients originally diagnosed
with schizophrenia (AP1012 and AF'1035, patients 1
and 11, respectively, in Pulver et al. ) were found
to have a form of BPD when subjected to our diagnostic
testing. A consensus diagnosis of schizoaffective disor-
der was made by both groups for patient AP1079
(patient 14 in Pulver et al. ). The discrepancies
may be due to the inherent difficulties in establishing
a psychiatric diagnosis in adolescents, especially in
the learning-disabled population. However, the finding
that these patients responded to mood stabilizers, such
as valproate and lithium, is more consistent with the
diagnosis of a mood disorder (Papolos, unpublished ob-
A significant number of VCFS patients diagnosed
with bipolar spectrum conditions are hemizygous for
COMT158met, the low activity allele. The strongest as-
TABLE 11. Frequency of Codon 1081158 Polymorphism in Controls
Allele frequency Genotypes
Population (no. of chromosomes)
VCFS parents (42)
Metmet MetNal Val/Val
Association of COMT With VCFS
Award. D.F.P. was a recipient of an NIMH Physician
Scientist Career Development Award. B.M. was a re-
cipient of a grant from the National Alliance for Re-
search on Schizophrenia and Depression (NARSAD)
and the March of Dimes Basil O’Conner Starter
Scholar Research Award. R.K. was supported by NIH
grant HD31601. We thank Christine Carlson for excel-
lent technical assistance, as well as the patients and
families who participated in this study.
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TABLE 111. Frequency of Codon 108/158 Polymorphism
in VCFS Patients With Psychiatric Illness’
P = 0.078
P = 0.22
P = 0.13
BPI, BPII, SAM
P = 0.08
BPI, BPII, SAM, CY
P = 0.046”
BPI, BPII, CY
P = 0.035*
Rapid cycling BPD
P = 0.013*
t Allele frequencies under different diagnostic schemes. BPI, bipolar
disorder with mania; BPII, with hypomania; CY, cyclothymia; SAM,
schizoaffective disorder, manic subtype; ADHD, ADD, attention
deficit disorder with and without hyperactivity. Statistical signifi-
cance was determined by one-tailed Fisher’s exact test.
* P < 0.05.
sociation was found in patients diagnosed with rapid-
cycling BPD. Every COMT allele found in this sub-
group of patients was COMT158met. This suggests that
in some patients with VCFS, an increase in catechol-
amine neurotransmission, caused by low COMT activ-
ity, can induce an unstable form of BPD. This hypothe-
sis is consistent with observations made in BPD
occurring in the general population, in which a rapid-
cycling course may develop following treatment with
tricyclic antidepressants and monoamine oxidase in-
hibitors, both of which increase transsynaptic cate-
cholamines [Altshuler et al., 19951. In this context, it is
interesting to note that 2 patients (VCF-1, BM78) in
this study appeared to develop rapid-cycling BPD
within days of being treated with methylphenidate,
a drug that inhibits the dopamine transporter.
Methylphenidate had been prescribed after the pa-
tients were diagnosed with ADHD by their private
physicians. This diagnosis was not supported using our
rigorous diagnostic criteria. Rapid cycling persisted af-
ter methylphenidate treatment was discontinued.
The results of this study suggest that an analysis of
COMT158met in BPD occurring in the general popula-
tion, and in particular, in those who develop a rapid-
cycling course, would be of interest. However, so far, we
have not detected an association in 60 patients with
BPD (unpublished observations). Populations of bipo-
lar patients selected for rapid cycling or other sub-
groups have not yet been analyzed.
If confirmed, the association of the COMT codon 1081158
polymorphism with bipolar spectrum conditions and
rapid-cycling BPD in VCFS would be the first descrip-
tion of a specific genetic variant associated with a mood
disorder. However, a more extensive analysis and repli-
cation in an independent set of patients will be required.
H.M.L. was supported by the Carmel Hill Fund and
was a recipient of the Stanley Foundation Research
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