Is PSP a Disease?

The neurodegenerative diseases are starting to merge. The most obvious level of commonality lies at the cellular level of pathogenesis, where each disease is now hypothesized to include protein misfolding, templating, intercellular spread and damage by oligomers. Within the tauopathies, there is major overlap among “diseases,” as shown in this superb diagram from David Williams and Andrew Lees (Lancet 2009).

The blue, green and purple areas are pathological syndromes and the reddish ones are clinical syndromes. Note that all of the patients with Richardson’s syndrome and PSP-parkinsonism have classic PSP pathology, but the reverse is not true. Corticobasal syndrome is only about half explained by corticobasal degeneration pathology (though the diagram suggests about 85%), most of the rest being PSP and frontotemporal dementia pathology. Similar shortfalls in clinicopathological correlation underlying our traditional definition of a “disease” plague the rest of the tauopathy diagram. A similar diagram can be made for the α-synucleinopathies.

How to explain this to our patients? Our students? Ourselves? I like to think of neurodegenerative diseases as a set of spectrums. As there are only a limited number of neural systems available to damage, inevitably some parts of some of the spectrums will overlap in their anatomical, therefore clinical, phenotypes. This idea may seem unsatisfying to our traditional, neat system of clinicopathological pigeonholes. It’s not as easy to digest as, for example, the “autism spectrum,” where we don’t yet have the messy variable of pathological correlates to contend with. But this state of neo-nosologic confusion is only temporary. Before too long, we will have a long list of genomic, epigenetic, toxic, proteomic variants along with just plain stochastic events that in combination produce neurodegenerative disease. We will then have an understanding of such diseases that is more sophisticated and rational than the current combination of microscopical, biochemical and clinical abnormalities. These insights will render our present concept of “a disease” obsolete and make it much easier to devise prevention for most of these conditions.

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