Beta-amyloid Precursor Research Articles

Treatment of Stroke with a Synthetic Liver X Receptor Agonist, TO901317, Promotes Synaptic Plasticity and Axonal Regeneration in Mice

In this study, we tested the hypothesis that TO901317 promotes synapse plasticity and axonal regeneration after stroke. Adult male C57BL/6J mice were subjected to middle cerebral artery occlusion (MCAo) and treated with or without TO901317 starting 24 h after MCAo daily for 14 days. Axonal damage and regeneration were evaluated by immunostaining. TO901317 significantly increased synaptophysin expression and axonal regeneration, as well as decreased the expressions of amyloid betaA4 precursor protein and Nogo receptor (NgR) in the ischemic brain. To test whether TO901317 regulates the phosphorylation of phosphatidylinositol 3-kinase (p-PI3K) and Akt (p-Akt) activity in the ischemic brain, MCAo mice were treated with or without TO901317 starting 24 h after MCAo daily for 4 days and were then killed at 5 days after MCAo. TO901317 treatment significantly increased p-PI3K and p-Akt activity, but did not increase total PI3K expression in the ischemic brain. Using primary cortical neuron (PCN) culture, TO901317 significantly increased synaptophysin expression, p-PI3K activity, and decreased NgR expression compared with nontreated controls. TO901317 also significantly increased neurite outgrowth, and inhibition of the PI3K/Akt pathway by LY294002 decreased neurite outgrowth in both controls and TO901317-treated groups in cultured hypoxic PCN. These data indicate that TO901317 promotes synaptic plasticity and axonal regeneration, and that PI3K/Akt signaling activity contributes to neurite outgrowth.

Lack of evidence to support the association of polymorphisms within the alpha- and beta-secretase genes (ADAM10/BACE1) with Alzheimer's disease

Cleavage of the amyloid precursor protein (APP) occurs through either an amyloidogenic or a non-amyloidogenic pathway. The first results in the generation of beta-amyloid (Aβ) and is initiated through cleavage by the beta-site amyloid beta A4 precursor protein-cleaving enzyme 1 (BACE1). The second precludes the formation of Aβ through cleavage by alpha-secretase, an enzyme's activity demonstrated in a disintegrin metalloproteinase, ADAM10. To assess the contribution of variants in the BACE1 and ADAM10 genes we used a detailed fine mapping approach. Genotyping of 11 single nucleotide polymorphisms covering the complete BACE1 gene, and 27 covering the entire ADAM10 gene, revealed no single-marker or haplotypic association with AD. We conclude that, in this present study, neither ADAM10 nor BACE1 present with any evidence to suggest that they are major candidate genes involved in conferring risk for AD.

AZD2184: a radioligand for sensitive detection of β‐amyloid deposits

The presence of beta-amyloid plaques in brain is a hallmark of Alzheimer's disease (AD) and serves as a biomarker for confirmation of diagnosis postmortem. Positron emission tomography (PET) radioligands such as Pittsburgh compound B ([(11)C]-2-(3-fluoro-4-methylamino-phenyl)-benzothiazol-6-ol) (PIB) binds selectively to beta-amyloid and are promising new tools supporting the clinical diagnoses of AD. In addition, such methodology may be useful for evaluation of new drugs aiming at reduction of amyloid plaque load. The objective of this study is to develop a new amyloid selective PET radioligand with higher signal-to-background ratio when compared with existing amyloid PET ligands. The lead compound, AZD2184, (2-[6-(methylamino)pyridin-3-yl]-1,3-benzothiazol-6-ol) was found to have high affinity for amyloid fibrils in vitro (K(d): 8.4 +/- 1.0 nM). Two minutes after i.v. administration in rats, about 1% of the dose was in brain. In vitro autoradiography on cortical brain sections from amyloid-beta precursor protein/presenilin 1 (APP/PS1) mice and AD patients showed that while [(3)H]AZD2184 and [(3)H]PIB are mutually displaceable, [(3)H]AZD2184 displays a higher signal-to-background ratio primarily by virtue of lower background binding levels. The ratio of binding ability in prefrontal cortex (high plaque load) to subcortical white matter (background) was 4.5 for [(3)H]AZD2184 and 0.8 for [(3)H]PIB at 1 nM. In adjacent cortical sections from APP/PS1 mouse as well as from AD cortical tissue, [(3)H]AZD2184 and antibodies to human beta-amyloid labeled identical structures. In vivo administration of [(3)H]AZD2184 to APP/PS1 mice further showed that [(3)H]AZD2184 labels amyloid deposits with low non-specific background binding. Taken together, the pre-clinical profile of AZD2184 in relation to the reference ligand PIB, suggests that (11)C-labeled AZD2184 is a potential radioligand for PET-visualization of beta-amyloid deposits in the living human brain.

P1-403: Molecular insights into mechanism of alpha synucklein (ASN)–evoked cell death: The role of ASN in the progression of amyloid-beta (AB)–mediated mitochondria dysfunction

The last data indicated that about 60% of sporadic and familial Alzheimer Disease (AD) patients contain in the brain Levy bodies in which ASN is fundamental component. However, the role of ASN in AB toxicity and in pathomechanism of AD is unknown. The relationship between ASN, its neurotoxic fragment, peptide NAC and AB remains unclear. The aim of our study was to analyzed the involvement of ASN in AB peptide secretion and in mechanism of AB evoked mitochondria dysfunction and cell death. Rat pheochromocytoma PC12 cells transfected with AB precursor protein bearing Swedish double mutation (APPsw) and control PC12 cells transfected with empty vector were used in this study. Our data showed that non aggregated ASN(10uM) induced 2-fold increase of AB secretion from control and APPsw PC12 cells. Moreover, ASN and NAC peptide (10uM) decreased viability of PC12 cells by about 50 and 70% respectively and potentiated AB induced apoptosis by enhancement of caspase 3 activity .Inhibitor of caspase-3 (Z-DEVD-FMK 100uM) and mitochondrial permeability transition pore blocker, cyclosporine A (2uM) protected PC12 and APPsw transfected cells against ASN and AB evoked cells death. These inhibitors had no effect when APPsw cell were additionally treated with ASN. Then the role of nitric oxide (NO) in mechanism of ASN and AB toxicity was indicated using specific inhibitors of different isoforms of NO synthases. Our data presented ameliorating effect of neuronal and inducible NOS inhibitors on ASN induced PC12 cells death and the lack of such a effect in APPsw cells treated with ASN where AB itself significantly activates nitrogenic stress. Our results indicate that ASN enhanced the release and toxicity of AB peptides leading to NO mediated irreversible mitochondria dysfunction and caspase dependent apoptotic cells death. Supported by: MS&HE grant 2PO5A 04129 and MS&HE scientific network No 28/E-32/SN-0053/2007

YWK-II protein/APLP2 in mouse gametes: Potential role in fertilization

YWK-II protein is a sperm membrane component, structurally related to human placenta amyloid precursor protein homolog (APPH) and rat amyloid precursor-like protein 2 (APLP2). Its transmembrane-cytoplasmic domain has high homology (70.6%) with that of betaA4-amyloid precursor protein (APP) found in brain plaques of subjects with Alzheimer's disease. The gene encoding the YWK-II protein is expressed in various mammalian cells and tissues. In the present study, splicing patterns of YWK-II mRNA and the content of YWK-II mRNA in mouse testes, eggs, and cumulus cells were determined. Three different YWK-II transcripts were found in testes and eggs, while cumulus cells contained an additional transcript. In mouse eggs, the content of YWK-II transcript exceeded that of APP. An alternative splicing region was located in the vicinity of the kunitz protease inhibitor (KPI) domain, which may be the basis for the formation of multiple transcripts. YWK-II protein was immunolocated in male and female gametes. It was localized in the plasma membrane of mouse eggs and spermatozoa. In the male reproductive system of the mouse, the YWK-II gene was expressed in germ cells at various stages of differentiation. In mature spermatozoa, the YWK-II protein occurred in the plasma membrane enveloping the acrosome. Triggering the acrosome reaction incited a release of the YWK-II protein attached to the liberated membrane vesicles. The occurrence of the YWK-II protein in the plasma membranes of mouse gametes suggests its involvement in sperm-egg interaction.

Facilitation of Stress-induced Phosphorylation of β-Amyloid Precursor Protein Family Members by X11-like/Mint2 Protein

Beta-amyloid precursor protein (APP) is the precursor of beta-amyloid (Abeta), which is implicated in Alzheimer's disease pathogenesis. APP complements amyloid precursor-like protein 2 (APLP2), and together they play essential physiological roles. Phosphorylation at the Thr(668) residue of APP (with respect to the numbering conversion for the APP 695 isoform) and the Thr(736) residue of APLP2 (with respect to the numbering conversion for the APLP2 763 isoform) in their cytoplasmic domains acts as a molecular switch for their protein-protein interaction and is implicated in neural function(s) and/or Alzheimer's disease pathogenesis. Here we demonstrate that both APP and APLP2 can be phosphorylated by JNK at the Thr(668) and Thr(736) residues, respectively, in response to cellular stress. X11-like (X11L, also referred to as X11beta and Mint2), which is a member of the mammalian LIN-10 protein family and a possible regulator of Abeta production, elevated APP and APLP2 phosphorylation probably by facilitating JNK-mediated phosphorylation, whereas other members of the family, X11 and X11L2, did not. These observations revealed an involvement of X11L in the phosphorylation of APP family proteins in cellular stress and suggest that X11L protein may be important in the physiology of APP family proteins as well as in the regulation of Abeta production.

The human prion octarepeat fragment prevents and reverses the inhibitory action of copper in the P2X4 receptor without modifying the zinc action

Human prion protein fragments (PrP60-67 or PrP59-91) prevented and reversed the inhibition elicited by 5 micro m copper on the P2X4 receptor expressed in Xenopus laevis oocytes. A 60-s pre-application of 5 micro m copper caused a 69.2 +/- 2.6% inhibition of the 10 micro m adenosine triphosphate (ATP)-evoked currents, an effect that was prevented by mixing 5 micro m copper with 0.01-10 micro m of the PrP fragments 1-min prior to application. This interaction was selective, as PrP59-91 did not alter the facilitatory action of zinc. The EC50 of PrP60-67 and PrP59-91 for the reduction of the copper inhibition were 4.6 +/- 1 and 1.3 +/- 0.4 micro m, respectively. A synthetic PrP59-91 variant in which all four His were replaced by Ala was inactive. However, the replacement of Trp in each of the four putative copper-binding domains by Ala slightly decreased its potency. Furthermore, the application of 10 micro m PrP59-91 reversed the copper-evoked inhibition, restoring the ATP concentration curve to the same level as the non-inhibited state. Fragment 139-157 of betaA4 amyloid precursor protein also prevented the action of copper; its EC50 was 1.6 +/- 0.1 micro m; the metal chelator penicillamine was equipotent with PrP60-67, but carnosine was significantly less potent. Our findings highlight the role of PrP in copper homeostasis and hint at its possible role as a modulator of synapses regulated by this trace metal.

Increased superoxide dismutase and Down’s syndrome

The enzyme superoxide dismutase (SOD) is a constitutive enzyme coded by a gene located in Chromosome 21 (21q22.1). Thus, the tissues from patients with trisomy 21 contain 50% more SOD activity. It is often suggested that the increased SOD content in the cells of Down’s syndrome patients is responsible for many of the neurological symptoms of this disease. This hypothesis is not supported by most of the available data. In this paper we discuss why the increased SOD activity should not influence neuronal function and propose, instead, that the main problem may be an overexpression of other genes also located in chromosome 21 such as the beta amyloid precursor, as well as oncogenes and other Down’s syndrome-related genes. We also propose that the increased SOD may be, instead, responsible for the increased incidence of Down’s syndrome in children of older women. The augmented antioxidant protection resulting from an extra copy of chromosome 21 may, with time, selectively protect human oocytes from apoptosis, increasing their proportion with age, explaining the higher incidence of this disease.

Extracellular domain of YWK-II, a human sperm transmembrane protein, interacts with rat Müllerian-inhibiting substance.

The YWK-II protein in human spermatozoa is structurally related to the betaA4-amyloid precursor protein of Alzheimer disease and has high similarity with amyloid precusor homologues. Antibodies to the YWK-II protein agglutinate human spermatozoa and may be a potential cause of infertility. In the present study, a yeast two-hybrid system (MATCHMAKER Two-Hybrid System 2; Clontech, Palo Alto, CA) was used to screen a rat ovary cDNA library for potential ligands capable of interacting with the YWK-II component. Müllerian-inhibiting substance was found to interact with the extracellular domain of YWK-II protein. The interaction was confirmed by a binding experiment in vitro and surface plasmon resonance assays. The recombinant Müllerian-inhibiting substance can significantly increase the viability and longevity of human spermatozoa after 5 and 22 h of incubation, presumably through binding the YWK-II component on the sperm membrane. The results of this study indicate that the YWK-II sperm membrane protein may function as a receptor for Müllerian-inhibiting substance.

Evidence for the binding of a human sperm component with diaphanous protein.

The YWK-II component of human sperm membrane is related to the betaA4-amyloid precursor protein (APP) of Alzheimer's disease. A yeast 2-hybrid system was used to screen a mouse testis cDNA expression library for potential ligands capable of interacting with the extracellular domain of the YWK-II component. One of the bound proteins was identified as hDIA1, which has 96% identity with p140mDia. These proteins are members of the formin homology family and participate in cytokinesis and organization of the actin cytoskeleton. By interacting with these diaphanous proteins, the YWK-II component may be involved in germ cell differentiation and in the structural formation of the acrosome.

Expression and characterization of the human YWK-II gene, encoding a sperm membrane protein related to the alzheimer betaA4-amyloid precursorprotein.

The YWK-II cDNA, RSD-2, encoding a sperm membrane protein was isolated from a rat testis cDNA expression library. Using the RSD-2 insert in combination with rapid amplification of cDNA ends (RACE), the corresponding human gene was isolated from a human testis cDNA expression library. The human testis cDNA, HSD-2, is 3654 bp in length and contains an open reading frame of 763 codons. Hydropathicity analysis showed that the deduced polypeptide is a single strand transmembrane protein. The deduced polypeptide has partial homology with the amyloid precursor protein (APP) and high homology with the amyloid precursor homologue, APLP2/APPH. The YWK-II gene was mapped and assigned to human chromosome locus: 11q24-25. Northern blotting of various human tissue RNAs using the HSD-2 cDNA as a probe showed that the gene is transcribed ubiquitously. The cytoplasmic domain of HSD-2 was expressed in Escherichia coli. In-vitro studies showed that the recombinant polypeptide bound to a GTP-binding protein (G(o)) and was phosphorylated by protein kinase C and cdc2 kinase. In mammalian F11 cells, the recombinant polypeptide was found to be coupled to G(o). Thus, the YWK-II component has the characteristics of a G(o)-coupled receptor and may be involved in G(o)-mediated signal transduction pathway. Protein kinase C and cdc2 kinase may regulate this pathway in spermatozoa by phosphorylating the cytoplasmic domain of the YWK-II component.

A beta A4 amyloid precursor protein gene and Alzheimer's disease.

Alzheimer's disease is a senile dementia caused by progressive neurodegeneration of the central nervous system. One of the most prominent pathological characteristics is beta A4 amyloid deposition in senile plaques in the brain parenchyma and in cerebral blood vessels. beta A4 amyloid is processed from a larger integral membrane protein, the beta A4 amyloid precursor protein. Different pathogenic mutations in this protein have been detected in a small number of Alzheimer's disease families. Here functional implications of these mutations on the processing of the precursor protein and the beta A4 amyloid deposition will be discussed with respect to the pathogenesis of Alzheimer's disease and related disorders.

Inflammatory reaction in experimental autoimmune encephalomyelitis (EAE) is accompanied by a microglial expression of the βA4‐amyloid precursor protein (APP)

Neuropathological studies of the amyloid depositions and senile plaques in the brains of elderly patients or patients diagnosed with Alzheimer's disease reveal the conspicuous presence of numerous proteins which are usually expressed during reactions of the immune system. This has led to speculations that the pathomechanism of neurodegenerative diseases might involve inflammatory processes. These considerations constitute the theoretical basis for therapeutic intervention with antiinflammatory drugs in neurodegenerative diseases. Here, we show that the beta A4-amyloid precursor (APP) is rapidly induced in microglia in a model of experimental autoimmune encephalomyelitis (EAE). Using specific monoclonal antibodies against APP, the first glial cells newly expressing APP immunoreactivity were found at an early preclinical stage, i.e., 24 h after T-cell transfer. At the peak of clinical disease (6 days after T-cell transfer), numerous characteristically ramified cells were strongly positive for APP. Based on morphology and double-labeling, most of the de novo APP-expressing cells were identified as microglia. Additionally, APP-immunoreactive round cells were detected in and around perivascular infiltrates. Reflecting the course of the clinical disease, the induction of APP immunoreactivity terminated in the postclinical stage, i.e., 14 days after T-cell transfer. These results support earlier work demonstrating that microglia can rapidly de novo synthesise APP not only in response to direct nerve injury (Banati et al: Glia 9:199, 1993a) but also in immune-mediated disease. Apart from its possible therapeutic relevance, such a production of APP--reminiscent of an acute phase protein-suggests a role of APP in immune and repair mechanisms of the central nervous system.

Characterization of the high affinity heparin binding site of the Alzheimer's disease beta A4 amyloid precursor protein (APP) and its enhancement by zinc(II).

The Alzheimer's disease beta A4 amyloid precursor protein (APP) has been shown to be involved in a diverse set of biological activities including regulation of cell growth, neurite outgrowth and adhesiveness. The APP and amyloid protein precursor-like proteins (APLP1 and APLP2) belong to a superfamily of proteins that are probably functionally related. In order to characterize the cell adhesion properties of APP the brain specific isoform APP695 was purified and used to assess the binding to heparin, a structural and functional analogue of the glycosaminoglycan heparan sulfate. We show that APP binds in a time dependent and saturable manner to heparin. The salt concentration of 620 mM at which APP elutes from heparin Sepharose is greater than physiological. The apparent equilibrium constant for dissociation was determined to be 300 pM for APP binding to heparin Sepharose. A high affinity heparin binding site was identified within a region conserved in rodent and human APP, APLP1 and APLP2. This binding site was located between residues 316-337 of APP695 which is within the carbohydrate domain of APP. We also demonstrate an interaction between this heparin binding site and the zinc(II) binding site which is conserved in all members of the APP superfamily. We show by using an automated surface plasmon resonance biosensor (BIAcore, Pharmacia) that the affinity for heparin is increased two- to four-fold in the presence of micromolar zinc(II). The identification of zinc-enhanced binding of APP to heparan sulfate side chains of proteoglycans offers a molecular link between zinc(II), as a putative environmental toxin for Alzheimer's disease, and aggregation of amyloid beta A4 protein.

Extracellular Matrix Influences the Biogenesis of Amyloid Precursor Protein in Microglial Cells

During axotomy studies, we discovered that the beta A4-amyloid precursor protein (APP) participates in immune responses of the central nervous system. Since microglia constitute the main immune effector cell population of this response, we used the murine microglial cell line BV-2 to analyze immune response-related APP expression. We show that interaction of microglia with the extracellular environment, particularly components of the extracellular matrix, affects APP secretion as well as intracellular APP biogenesis and catabolism. Fibronectin enhanced APP secretion and decreased the level of cellular mature transmembrane APP, whereas laminin and collagen caused a decrease in secretion and an accumulation of cellular mature APP and APP fragments. Our results demonstrate that APP plays a fundamental role in the regulation of microglial mobility, i.e. migration, initial target recognition, and binding. The decrease in APP secretion and the concomitant increase in cellular mature APP were accompanied by an accumulation of C-terminal APP fragments. Enrichment of APP and APP fragments is assumedly based on inhibition of catabolic processes that is caused by a disorganization of the actin microfilament network. These observations provide evidence that microglia, which are closely associated with certain amyloid deposits in the brain of Alzheimer patients, can play a key role in initial events of amyloidogenesis by initiating accumulation of APP and also of amyloidogenic APP fragments in response to physiological changes upon brain injury.

The Rat Central Nervous System Expresses Alzheimer's Amyloid Precursor Protein APP695, but Not APP677 (L‐APP Form)

A novel splicing form of beta A4 amyloid precursor protein (APP) lacking exon 15, corresponding to 18 residues, was first reported in leukocytes and then in ubiquitous organs. To determine which APP molecules (APP695, APP751, or APP770) either with (N-APP) or without (L-APP; leukocyte-derived APP) exon 15 were expressed in various organs, we investigated the alternative splicing at exon 15 in the rat brain, kidney, heart, and testis by a PCR analysis of reverse-transcribed RNA and Southern blot analysis. Regarding APP695 without exons 7 and 8, L-APP was either seldom or never expressed in the brain, whereas both N- and L-APP were expressed in other organs. On the other hand, regarding APP751/770 containing exon 7, which codes for the Kunitz-type serine protease inhibitor domain, both N- and L-APP were expressed in all the organs examined, including the brain. These results suggest that a particular alternative regulation system related to exon 15 might be present in only APP695 of the brain and influence the proteolytic processing of APP.

Proteolysis at the secretase and amyloidogenic cleavage sites of theβ-amyloid precursor protein by acetylcholinesterase and butyrylcholinesterase using model peptide substrates

1. It was recently proposed that acetylcholinesterase (AChE), in addition to its esteratic activity, has proteolytic activity such that it may cleave the beta-amyloid precursor (beta-APP) within the beta-amyloid sequence. The purpose of this paper was to examine further whether AChE or butyrylcholinesterase (BuChE) had associated proteinase activity that was involved in the metabolism of beta-APP. 2. The ability of various preparations of AChE and BuChE to hydrolyze two synthetic fragments of beta-APP695 as model substrates containing the normal and aberrant cleavage sites was studied. 3. Digestion of these synthetic substrates with commercial preparations of Electrophorus electricus AChE indicated the presence of a trypsin-like proteolytic activity cleaving each peptide at the carboxy-terminal side of an internal lysine residue. 4. Purification of the trypsin-like proteinase activity by aminobenzamidine affinity chromatography yielded a preparation that was devoid of AChE activity but retained all of the proteinase activity. 5. Amino-terminal sequence analysis of this preparation showed that the first 13 amino acid residues were identical to beta-pancreatic trypsin. 6. These data indicate that the proteinase activity found in these commercial preparations of AChE is due to contamination with trypsin.

Identification and differential expression of a novel alternative splice isoform of the beta A4 amyloid precursor protein (APP) mRNA in leukocytes and brain microglial cells.

The gene for the beta A4-amyloid precursor protein (APP) consists of 19 exons which code for a typical N- and O-glycosylated transmembrane protein with four extracellular domains followed by the transmembrane domain and a short cytoplasmic domain. The beta A4-amyloid sequence is part of exons 16 and 17. Several APP isoforms can be generated by alternative splicing of exons 7 and 8, encoding domains with homologies to Kunitz-type protease inhibitors and the MRC OX-2 antigen, respectively. The mechanism by which the pathological beta A4 is generated is unknown, it is however a critical event in Alzheimer's disease and is distinct from the normally occurring cleavage and secretion of APPs within the beta A4 sequence. We report here for the first time considerable APP mRNA expression by rat brain microglial cells. In addition we showed by S1 nuclease protection and polymerase chain reaction analysis of reverse transcribed RNA (RT-PCR) that T-lymphocytes, macrophages, and microglial cells expressed a new APP isoform by selection of a novel alternative splice site and exclusion of exon 15 of the APP gene. This leads to a transmembrane, beta A4 sequence containing APP variant, lacking 18 amino acid residues close to the amyloidogenic region. The use of this novel alternative splice site alters the structure of APP in close proximity to the beta A4 region and thus may determine a variant, potentially pathogenic processing of leukocyte-derived APP in brain.

The seminal role of beta-amyloid in the pathogenesis of Alzheimer disease.

New molecular information about Alzheimer disease (AD) is appearing at an unprecedented rate. Much interest centers on the beta A4 amyloid protein, which is progressively deposited in senile plaques and blood vessels in AD brain tissue. The discovery that some kindreds with familial AD have a mutation in the gene coding for the beta A4 amyloid precursor protein (APP) suggests that this mutation alone may be sufficient to cause the full spectrum of clinical and pathological changes that characterize AD. Although APP point mutations may turn out to be relatively rare causes of AD, the idea that accelerated beta A4 deposition is an early and critical event in many patients continues to gain support from studies in humans, animals, and cultured cells. Identification of the biochemical steps leading to production of the beta A4 peptide from APP is now a critical issue. Recent reports indicate that normal lysosomal processing pathways can produce carboxyl-terminal fragments of APP that contain the entire beta A4 sequence, and are therefore potentially amyloidogenic. The mechanisms by which such intermediate forms are further processed and released, resulting in extracellular beta A4 deposits in plaques and vessels, are yet to be determined. It is likely that full elucidation of the beta A4-producing pathways will ultimately yield new therapeutic approaches to this complex and tragic disorder.