Brainstem Evoked Response Audiometry biomarkers

in patients with schizophrenia and adult ADHD.

E. Baghdassarian 1, J. Källstrand 2, S. Nielzén 3, T. Lewander 4
1
Uppsala University Hospital, Psychiatry, Uppsala, Sweden; 2 SensoDetect AB, Research & Development, Lund, Sweden; 3 Lund University, Psychiatry, Lund, Sweden;
4
Uppsala University, Neuroscience, Uppsala, Sweden

Background Results
Brainstem auditory evoked response recordings are usually characterized by measuring peak (I – The Uppsala Study 2009-2012*
VII) latencies in milliseconds (ms) and amplitudes in microvolt.The peaks correspond to brainstem * See Abstract by Baghdassarian et al. ECNP 2014.
anatomical structures of the auditory pathways – Figure 1. The waveforms of the auditory evoked
The aim of the study was to evaluate the present method as objective diagnostic support for
responses during 10 ms after click sound stimuli have previously been shown to be abnormal in pa-
schizophrenia and adult ADHD vs. healthy controls using blind evaluation of brainstem audiom-
tients with schizophrenia and other mental disorders. The changes of the analog waveforms have,
etry recordings.
however, been difficult to characterize and quantify by just using latencies and amplitudes.
Hypotheses: The Schizophrenia Index is positive for patients with schizophrenia, but negative for
I II III IV-V VI VII healthy controls and patients with adult ADHD. The ADHD-Index is positive for patients with adult
ADHD, but negative for healthy controls and patients with schizophrenia
Outcome:
Healthy n=58 Schizphr n=29 ADHD n=24
Match vs. Clinical dx 50 24 21
No match 8 5 3
Sensitivity 1
86.2% 82.7% 87.5%
Specificity2 - 92.7% 93.1%
1
Sensitivity: Fraction of subjects with schizophrenia or ADHD having a positive test result.
2
Specificity: Fraction of subjects without schizophrenia or ADHD having a negative test result.

Figure 1.
Figure 1 shows the analog waveform after a standard sound stimulus in relation to the brainstem auditory pathways. Ro-
man numerals indicate the peaks of the curve as commonly used.
Objectives
The objectives of the present investigations was to apply novel techniques of analyzing the brain-
stem auditory response waveforms with the aim to identify characteristics (traits) for neuropsychi-
atric disorders that might be utilized as biomarkers in support of clinical diagnoses.
Conclusion
The present method with detailed analyses of brainstem audiometry waveforms iden-
tified patients with schizophrenia and adult ADHD meeting DSM-IV diagnostic cri-
teria, respectively, with high sensitivity and specificity. The method deserves further
investigations in order to confirm the utility of the present biomarkers in supporting
these clinical diagnoses. The findings also indicate variability in anatomy and neu-
ronal organization of the brainstem that differentiates the audiograms of the two
disorders from each other and from healthy controls. The results with the present
method show promise for finding similar biomarkers in patients with other CNS dis-
orders.

Methods
1. A square-shaped click pulse and an additional 4 different sound stimuli (high and low pass fil- 8. Figure 3 shows the traits used for male patients with schizophrenia, and the accompanying
tered, forward and backward masking) were presented to both ears, some of them repeatedly. table poster
ECNP describes the2014,
2014,
ECNP poster details of each trait.
corrected Schizophrenia, males
Each click sound was presented 1024 times to produce the respective waveform. corrected Schizophrenia, males
Line = part of waveform Schizophrenia, males
2. Digitation of the analog waveforms was employed (1541 data points per 10 milliseconds, 154 Lineto=schizophrenia
D = distance part of waveform
D = distance
reference curve
to schizophrenia reference curve
Dot = correlation with schizophrenia reference curve
data points per ms) that permits numerical and statistical calculations, such as distances and Dot =with
X = correlation correlation
healthywith schizophrenia
volunteer reference
reference curve curve
X = Amplitude
correlation with healthy volunteer reference curve
correlations between the whole or parts of median/mean waveforms from groups of subjects Diamond A
Diamond LDiamond
p
R SYM =Aleft
peak
p
= Amplitude
5
p symmetry
– right peak 5
p
including statistical tests.
D
Diamond L R SYM = left – right symmetry
SM7

x D
SM7
3. A new method (the moving minimum subtraction method; Källstrand et al, Neuropsychiatr Dis SM5 SM15
Treat 10:1011-1016, 2014), has been developed that permits peak separation of fused peaks
SM5 x SM6 SM12
SM15
1 µV 1 SM12
SM6
and baseline adjustment of troughs between peaks (Figure 2). µV x SM13
x SM13
SM14
Schiz vs. Healty Controls ADHD vs. Healty Controls
D SM1
D SM1
SM14

Unprocessed Unprocessed
V V
III III
I I
VI VI

0
x SM10
x SM10
x SM2
x SM2
SM3,SM4
SM3,SM4
0 ms
ms
W=136 W=136

V V Figure 3.
III
VI
III
VI
Traits differentiating details of the median standard curve for schizophrenia in males from the median standard curve for
I I
male healthy controls. The traits are further described in Table 1.

Table 1. Male schizophrenics traits

Trait ID Stimulus Time Processing L/R Comparison Brainstem Structure
W=68 W=68
SM1 All sounds 2-3ms W136 Bilateral Correlation to schiz ref Pons
SM2 HP1 4.5-5ms W136 Right Correlation to healthy ref Inferior Colliculus
SM3 All sounds 7-9.5ms W136 Bilateral Correlation to schiz ref Thalamo-cortical
III V III V SM4 All sounds 7-9.5ms W68 Bilateral Correlation to schiz ref Thalamo-cortical
I VI I VI SM5 FM1 4.5-6.5ms W68 Bilateral Correlation to healthy ref Inferior Colliculus
SM6 All sounds 5-7ms W68 Bilateral Correlation to schiz ref Inferior Colliculus-thalamus

Figure 2. SM7 All sounds 2-9ms W68 Bilateral Distance to schiz ref Cochlear nucleus to thalamo-cortical
SM8 HP1 4.5ms W136 Right Lower amplitude of Peak V Lateral Lemniscus
Median ABR waveforms of 10 healthy volunteers (grey curve) compared with 10 patients with schizophrenia (black curve, SM9 HP2 4.5ms W136 Right Lower amplitude of Peak V Lateral Lemniscus
left panels) and with 10 patients with adult ADHD (dotted curve) The analogue waveforms (Unprocessed) were digitized to SM10 All sounds 1.5-2.5ms W136 Bilateral Correlation to healthy ref Cochlear nucleus
allow baseline alignments according to the moving minimum subtraction method using two windows (W=136 data points, SM11 FM2 7-8ms Unprocessed Bilateral Lower L-R correlation Inferior Colliculus
W=68 data points,), and to allow descriptive statistics and statistical analyses. SM12 LA 8.5-9ms W136 Left Correlation to schiz ref Thalamo-cortical
SM13 LA 8.5-9ms W136 Left Correlation to healthy ref Thalamo-cortical
SM14 LA 8.5-9ms W136 Right Correlation to schiz ref Thalamo-cortical

4. Due to sex differences, such as shorter latencies and higher amplitudes of the peaks in women, SM15 All sounds 7-9.5ms W136 Bilateral Correlation to schiz ref Thalamo-cortical

separate analyses of the audiograms from men and women were performed.
5. Due to left/right asymmetry of the auditory evoked response waveforms, separate analyses of 9. A trait index was calculated providing a percentage agreement with a diagnosis of schizophre-
the two sides are incorporated in the analyses when appropriate. nia or adult ADHD or no diagnosis depending on how many traits (1 or 2 important traits were
counted twice) a subject fulfilled per the total number of traits for diagnosis and gender. A cut-
6. Standard median curves of healthy (no-diagnosis) controls (n=40), patients with schizophrenia off set to ≥50% was used to indicate a diagnosis of schizophrenia and ADHD, respectively, vs.
(n=29), and adult ADHD patients (n=33) were prepared for men and women, respectively. In healthy controls in the analyses of subsequent subjects undergoing evaluation.
order to ascertain robust characteristics of the respective standard median curves, groups of
training and test sets of subjects were investigated.
7. Analyses of differences between the standard median curves, resulted in identification of 15
and 17 traits (characteristics) that differentiated male and female patients with schizophrenia
from male and female healthy controls, respectively, and 11 and 17 traits differentiated male
and female patients with adult ADHD from male and female healthy controls.
P.1.c.011
Brainstem evoked response audiometry biomarkers in patients with schizophrenia and adult ADHD
E. Baghdassarian 1, J. Källstrand 2, S. Nielzén 3, T. Lewander 4
1Uppsala University Hospital, Psychiatry, Uppsala, Sweden
2SensoDetect AB, Research a Development, Lund, Sweden

3Lund University, Psychiatry, Lund, Sweden

4Uppsala University, Neuroscience, Uppsala, Sweden

Brainstem evoked response audiometry (BERA) recordings (peaks I–VII) are usually characterized by measuring
latencies in milliseconds (ms) and amplitudes in microvolt (µV). The peaks correspond to brainstem anatomical
structures of the auditory pathways. The waveforms of the recordings over 10ms have previously been shown to
be abnormal in patients with schizophrenia and other mental disorders. The changes of the analog waveforms
have, however, been difficult to characterize and quantify by just using latencies and amplitudes. Other
aberrancies have been observed, but not further characterized. In the present investigations novel techniques of
analyzing the BERA waveforms have been developed with the aim to identify characteristics that might be utilized
as biomarkers for neuropsychiatric disorders.

A set of 13 different sound stimuli (square wave click sounds with different frequencies and amplitudes including
forward and backward masking) was presented binaurally to healthy volunteers (no-diagnosis group; n=40) and
patients with DSM-IV diagnoses of schizophrenia (n=33) and adult ADHD (n=29). The analog BERA waveforms
were digitized (1541 data points per 10ms = 154 data points per ms) in order to permit quantification of
amplitudes (µV) with high resolution. A novel method [1] has been developed for additional processing and
baseline alignment of the troughs of the waveforms. In a first set of experiments approximately half of the
study participants were used as a training set in order to find differences between the two diagnostic groups and
controls; the other half was used as test set in order to secure stable characteristics for the respective diagnostic
groups. Female and male subjects were separated in these analyses due to previously known gender differences
in BERA waveforms (shorter latencies and higher amplitudes in females as compared with males).

Sets of 11–17 traits (markers) were found to characterize the schizophrenia group vs. the adult ADHD group vs.
no-diagnosis controls in female and male patients, respectively. Based on these traits an index was calculated
for each individual indicating percentage similarity with either of the diagnostic groups. The SensoDetect®-
Brainstem Evoked Audiometry (SD-BERA) method was subsequently applied in a separate clinical study with
groups of patients with schizophrenia (n=29) vs. adult ADHD (n=24) vs. no-diagnosis controls (n=58). The SD-
BERA recordings were evaluated blindly by investigators ignorant of the clinical diagnosis of the study
participants. In a formal de-blinding session the SD-BERA diagnoses were compared with the clinical DSM-IV
diagnoses (SCID-I). The sensitivity of the method for schizophrenia vs. no-diagnosis controls was 82.7a, for
ADHD vs. no-diagnosis controls 87.5a, and the specificity vs. no-diagnosis controls was 92.7 and 93.1a,
respectively. The SD-BERA test indicated ADHD in 1/29 patients with clinical schizophrenia, and schizophrenia in
1/24 patients with clinical ADHD.

The present study suggests that the SD-BERA method might provide useful biomarkers to support the clinical
diagnoses of schizophrenia and adult ADHD. The findings also indicate variability in the neuronal organization of
the brain stem with characteristics that differentiates the two neuropsychiatric disorders from each other and from
no-diagnosis controls. Further studies of the SD-BERA method are in progress.

1. Källstrand, J. Lewander, T., Bagdassarian, E., Nielzén, S., 2014. A new method for analyzing auditory brain-
stem response waveforms using a moving-minimum subtraction procedure of digitized analog waveforms.
Neuropsychiatr Dis and Treat (In press).

Citation: Eur Neuropsychopharmacol. 2014;24aSuppl   2):S187

Keywords
Biological markers
Schizophrenia: clinical
Diagnoses & classification