Molecular Genetics and Metabolism 117 (2016) 1218

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Molecular Genetics and Metabolism

journal homepage: www.elsevier.com/locate/ymgme

Psychiatric disorders in adolescent and young adult patients

with phenylketonuria
Filippo Manti a,1, Francesca Nardecchia a,b,1, Flavia Chiarotti c, Claudia Carducci d,
Carla Carducci d, Vincenzo Leuzzi a,
a
Department of Child and Adolescent Neuropsychiatry, SAPIENZA University of Rome, Via dei Sabelli 108, 00185 Rome, Italy
b
Department of Physiology and Pharmacology, SAPIENZA University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
c
Istituto Superiore di Sanit, Department of Cell Biology and Neuroscience, Viale Regina Elena 299, 00161 Rome, Italy
d
Department of Experimental Medicine, SAPIENZA University of Rome, Viale del Policlinico 155, 00161 Roma, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Background and objectives: Psychiatric symptoms are a challenging aspect in adolescent and adult early treated
Received 15 October 2015 phenylketonuric (ETPKU) patients. To assess the occurrence of psychiatric disorders we explored the presence
Received in revised form 12 November 2015 of symptoms requiring intervention and further investigated the link between psychiatric disorders, the quality
Accepted 12 November 2015 of biochemical control and cognitive functioning.
Available online 14 November 2015
Patients and methods: Forty-six ETPKU patients (aged 12 to 44) and 30 age-matched healthy controls were sub-
jected to cognitive and psychiatric assessment by means of self-report questionnaires and psychiatric interview.
Keywords:
Phenylketonuria
Psychiatric diagnoses, if detected, were made according to DSM-5 criteria. Concomitant IQ, historical and concur-
Psychiatric disorders rent biochemical metabolic controls were included in the statistical analysis.
Psychiatric symptoms Results: Twenty-ve out of 46 ETPKUs showed clinical scores on at least one scale of the psychiatric assessment
Vulnerability (7/30 in controls); anxiety and withdrawal were the most frequent self-reported symptoms. Seventeen patients
Outcome (and no controls) met criteria for a psychiatric diagnosis, most of them belonging to the Anxiety Disorders cate-
gory. The occurrence of psychiatric symptoms was not associated with the life-long and concurrent quality of
metabolic control but patients with good metabolic control (500 M) in the rst 11 years of life showed higher
frequency of psychiatric diagnosis (Fisher's exact p = .0300).
Discussion/conclusion: ETPKUs show a higher than normal vulnerability to psychiatric disorders, which cannot be
explained by the usual biochemical alterations inuencing intellectual outcome. Our data support the hypothesis
that the burden of the disease acts as psychological stress for children and their families. Possible involvement of
neuromediators in the pathogenesis of these complex symptoms requires further investigation.
2015 Elsevier Inc. All rights reserved.

1. Introduction neuropsychological and psychiatric problems [29] remain challenging

Phenylketonuria (PKU; OMIM #261600) is an inherited metabolic
cause of treatable intellectual disability due to a defect in the phenylal-
anine hydroxylase enzyme (PAH), which converts phenylalanine (Phe)
into tyrosine (Tyr) [1]. Despite the favorable clinical outcome of early-
treated PKU (ETPKU) subjects, when compared with late- or untreated
patients, a lower Intelligence Quotient (IQ) than expected and minor
Abbreviations: ETPKU, early treated phenylketonuria; IQ, intelligence quotient; Phe,
phenylalanine; WAIS-R, Wechsler Adult Intelligence Scale-Revised; IDC, Index of Dietary
Control.
Corresponding author at: Via dei Sabelli 108, 00185 Roma, Italy.
E-mail addresses: lippo.manti@uniroma1.it (F. Manti),
francesca.nardecchia@uniroma1.it (F. Nardecchia), avia.chiarotti@iss.it (F. Chiarotti),
claudia.carducci@uniroma1.it (C. Carducci), vincenzo.leuzzi@uniroma1.it (V. Leuzzi).
1
The authors wish it to be known that, in their opinion, the rst two authors should be
regarded as joint First Authors.
aspects of the disease.
In ETPKU children and adolescents a higher incidence of the follow-
ing have been reported: anxiety and depressive symptoms, social isola-
tion, physical complaints, hyperactivity [1012], attention problems
[1316], low self-esteem, lower achievement motivation and impul-
siveness [17].
Among adult PKU patients, depressive mood and anxiety are the
most frequently described psychiatric symptoms [1820], but
obsessive-compulsive symptom [8,21], phobia, and panic attacks [22]
are also reported. Nevertheless, a clinical characterization of psychiatric
symptoms and the link between intellectual development, quality of di-
etary control and psychiatric disorders, if any, have not been explored so
far.
The present study aimed to explore whether ETPKU subjects exhibit
an increased psychiatric vulnerability and the possible determining
factors.

http://dx.doi.org/10.1016/j.ymgme.2015.11.006
1096-7192/ 2015 Elsevier Inc. All rights reserved.
 F. Manti et al. / Molecular Genetics and Metabolism 117 (2016) 1218 13

2. Materials and methods
2.1. Participants
The sample consisted of 76 subjects (46 ETPKU and 30 healthy con-
trols). Forty-six subjects (29 females, 17 males; mean age = 22.6 years;
SD = 7.35; range 1244 years) were recruited among the PKU patients
diagnosed and followed-up at the Department of Paediatrics and Child
Neurology and Psychiatry in Rome (Table 1). The inclusion criteria
were: a) early diagnosis by neonatal screening program and early treat-
ment; b) genetically conrmed defect of PAH; c) age 12 years;
d) availability of biochemical data covering the patient's history from
the diagnosis until the time of the study.
The exclusion criteria included a) intellectual disability (IQ b 75);
b) the presence of neurological defects or neurological deterioration
(for patients who discontinued the diet).
PKU patients were classied according to plasma Phe concentrations
before treatment or under free diet as mild hyperphenylalaninaemia

Table 1
Demographic and clinical characteristics of the PKU sample.

Pt Age Sex Genotype Biochemical IDC (M) IDC (M) N Diet IQ Onset of psychiatric Psychiatric School Employed
ID (years/ phenotype 10 years and 11 years (yes/no) disorder disorder level
months) 11 months (years/months)

1 16/3 M p.[Arg176*]; c.[1066-11G NA] CPKU 451 973 Yes 120 14/0 SP Hs NA
2 22/1 M p.[Arg158Gln]; [Pro281Leu] CPKU 478 981 Yes 80 19/10 DD G Yes
3 20/0 F p.[Arg158Gln]; [Arg261Gln] MPKU 290 760 No 103 10/0 SP Us NA
4 13/1 M c.[1066-11 GNA]; p.[Tyr414Cys] MPKU 313 376 Yesa 94 9/6 GAD Ms NA
5 18/0 M p.[Gly325Cys]; c.[1066-11GNA] HPA 363 626 No 82 9/0 DD Ms NA
6 19/0 M p.[Arg408Gln]; [Arg261Gln] MPKU 297 565 Yesa 114 13/2 GAD Us NA
7 16/10 F p.[Arg408Gln]; [Tyr414Cys] MPKU 334 512 No 82 6/0 SM Hs NA
8 19/3 F p.[Leu194Pro]; [Arg261Gln] CPKU 517 1004 No 81 16/3 GAD G Yes
9 13/2 M p.[Leu48Ser]; [Leu369Leu] MPKU 436 452 Yesa 103 11/9 GAD Ms NA
10 13/0 F p. [Arg261Gln]; c.[1066-11G NA] MPKU 502 684 Yesa 84 9/4 GAD Ms NA
11 14/0 F p.[Arg 176*]; [Arg261Gln] CPKU 421 1033 No 83 9/8 GAD Ms NA
12 23/2 F p.[Arg 243*]; [Arg261Gln] MPKU 650 735 No 93 18/1 PD Us Yes
13 24/5 F p.[Arg261Gln]; c.[913-7ANG] CPKU 393 581 Yes 82 23/2 DD Ud No
14 35/0 F p. [Arg261*]; [Asp338Tyr] CPKU 335 716 No 85 32/0 DD G Yes
15 21/3 F p. [Pro281Leu]; [Pro281Leu] CPKU 335 956 No 75 12/0 GAD G No
16 25/3 F c.[DEL EX 3]; [1066-11GNA] CPKU 382 554 No 117 19/0 PD Us NA
17 22/1 M c. [1066-11GNA]; [?] HPA 396 904 No 85 18/5 PD Ud Yes
18 17/9 M p.[Arg408Trp]; [Arg408Trp] CPKU 584 911 No 94 G No
19 12/4 F p.[Arg408Trp]; [Arg408Trp] CPKU 498 764 Yes 84 Ms NA
20 18/4 M c.[1066-11 GNA];p.[Tyr414Cys] MPKU 358 642 Yesa 124 Us No
21 18/2 M p. [Pro281Leu]; [Asp338Tyr] MPKU 324 648 No 116 G Yes
22 13/8 M p.[Arg158Gln]; [Tyr414Cys] HPA 346 368 No 84 Ms NA
23 13/0 M p.[Asp59Val]; [Arg261Gln] MPKU 341 540 Yesa 88 Ms NA
24 26/0 F p. [Arg261Gln]; [Arg261Gln] MPKU 408 648 Yes 86 Ud Yes
25 27/6 F p. [Arg252Trp]; [Arg252Trp] MPKU 367 661 Yes 112 G Yes
26 24/6 F c. [1066-11GNA]; [?] MPKU 241 528 No 93 Us No
27 23/1 M p.[Tyr277Cys]; c.[842+1GNA] CPKU 478 477 No 109 Us No
28 26/3 F p.[Tyr277Cys]; c.[842+1GNA] CPKU 599 539.5 No 102 Ud Yes
29 22/1 F c.[441+5GNT]; p.[Arg158Gln] CPKU 567 811 No 88 G Yes
30 25/4 F c.[441+5GNT]; p.[Arg158Gln] CPKU 590 689 No 81 G Yes
31 26/5 F p.[Phe39del]; [Arg111*] CPKU 604 973 No 91 Ud No
32 26/5 F p.[Arg408Trp]; [Arg408Trp] CPKU 784 1169 No 90 Ud Yes
33 24/0 F p.[Asp207Ser]; [Pro281Leu] MPKU 333 460 No 107 Us NA
34 24/1 M p.[Trp187*]; [Trp187*] CPKU 513 852.5 No 95 G Yes
35 25/9 F p.[Leu48Ser]; [Phe55NLeufs] MPKU 353 736 Yesa 75 G Yes
36 28/6 F p.[Arg243*]; [?] CPKU 899 1035 No 75 G No
37 17/0 F c.[1066-11G NA]; [?] HPA 413 822 No 95 Ms NA
38 36/2 F p.[Arg261Gln]; c.[1315+1GNA] HPA 275 363 Yes 75 G No
39 12/0 M p.[Pro281Leu]; c.[Tyr387*] CPKU 680 1150 No 77 Ms NA
40 27/6 M c.[842+1GNA]; [1066-11GNA] CPKU 804 1455 No 84 G Yes
41 29/0 M p.[Arg158Gln]; c.[1066-11GNA] CPKU 549.6 1187 No 84 G Yes
42 27/0 F c.[1066-11G NA]; [1066-11GNA] CPKU 600 1048 Yes 96 Us No
43 44/0 F p.[Phe55Leu]; [Asp338Tyr] CPKU 260 652 Yes 105 G Yes
44 28/2 F p.[Arg408Trp]; [Arg408Trp] CPKU 750.3 912.5 No 104 Us No
45 32/6 F p.[Arg408Trp]; [Arg408Trp] CPKU 668.5 926.5 No 94 Ud Yes
46 36/0 F p.[Pro281Leu]; c.[913-7ANG] CPKU 778 610 Yes 94 Us Yes

Legend: SP: specic phobia; GAD: generalized anxiety disorder; DD: depressive disorder; SM: selective mutism; PD: personality disorder.
IDC: Index of Dietary Control, median value of Phe for the considered period.
Yrs/mo: years/months; NA: not applicable
CPKU: classical PKU (blood Phe at diagnosis or under free diet persistently N1200 M).
MPKU: mild PKU (blood Phe at diagnosis or under free diet persistently N600 b 1200 M).
HPA: persistent hyperphenylalaninemia (blood Phe at diagnosis or under free diet persistently N360 b 600 M).
School level: Ms: middle school; Hs: high school; G: graduate; Us: undergraduate school; Ud: undergraduate degree.
[?] = the mutation on the second allele was not found. MLPA test was negative.
a
Under Sapropterin treatment (15 mg/kg) since a minimum of 7 years.
14 F. Manti et al. / Molecular Genetics and Metabolism 117 (2016) 1218
(mild HPA): 360600 mol/L; mild PKU: 6001200 mol/L; classical
PKU: N1200 mol/L [23]. Of the 46 ETPKU, 26 were classical PKU, 15
were mild PKU and 5 were mild HPA.
Thirty healthy controls (HCs; 21 females and 9 males; mean age =
23.71 years; SD = 6.91; range 1340 years) were recruited through ad-
vertisements among middle school, high school and university stu-
dents. Patients and HCs had comparable gender ratio, age and group-
level according to socio-demographic background.
The study was approved by the local ethical committee and a written
informed consent was obtained from subjects or subjects parents or tu-
tors (for minors). Assessment of IQ and psychological characteristics of
ETPKU and HC were performed in a single session.
Phe, Tyr and Phe/Tyr ratio were analyzed on dry blood spot by tan-
dem mass spectrometry.
2.2. Metabolic control in PKU subjects
The following metabolic parameters were collected for each patient:
a) concurrent Phe level and Phe/Tyr ratio at the time of cognitive and
psychiatric assessment; b) Index of Dietary Control (IDC) computed as
mean of all yearly medians of Phe levels from the beginning of the
diet to the age of 10 years and 11 months; c) the IDC from 11 years to
the day of the assessment; d) the life-long IDC (from the start of treat-
ment to the day of the assessment); e) the standard deviation of Phe
(SD Phe) calculated from the start of the treatment to the day of the
assessment.
2.3. Cognitive performance
IQ was measured by Wechsler Intelligence Scale for children-III
(WISC-III) for patients 616 years of age [24] and by Wechsler Adult in-
telligence Scale- Revised (WAIS-R) for patients 17 years [25]. Level of
intelligence was classied within the normal range for IQ 75.
2.4. Psychiatric assessment
2.4.1. Categorical psychiatric diagnosis
All patients and controls underwent psychiatric interview in order to
assess the occurrence of psychiatric symptoms. The diagnosis was made
according to DSM-5 criteria.
2.4.2. Self-report questionnaires
The following tools were adopted in order to assess the occurrence
of psychiatric symptoms.
2.4.2.1. Achenbach System of Empirically Based Assessments (ASEBA) [26].
Subjects completed the Youth Self Report (YSR) or the Adult Self Report
(ASR) to measure psychiatric symptoms by 112 (YSR) or 126 (ASR)
questions on a 3 point scale (not true = 0, somewhat or sometimes
true = 1; very true/often true = 2). A total Problem score, two broad-
band scores (Internalizing and Externalizing Problems) and eight differ-
ent syndrome scales (Anxious/Depressed, Withdrawn/Depressed,
Somatic Complaints, Rule Breaking-Problems, Aggressive syndrome scale,
Social Problems (YSR) or Intrusive Problems (ASR), Thought Problems
and Attention Problems) were based on the 2001 prole. For this study
Social Problems of YSF and Intrusive Problems scales of ASR were not
taken into account for the statistical analysis. The scoring system gives
raw and standardized T-scores for the total symptoms, for internalizing
and externalizing symptoms, and for each syndrome scale. T scores at or
above 70 were considered clinically signicant while T-score of 6570
were considered borderline for emotional or behavioral problems.
2.4.2.2. Beck Depression Inventory (BDI-II) [27]. The BDI-II is a 21-item
self-report instrument that measures the intensity of depressive symp-
toms. Each item is assigned a score (0 = symptom absent; 1 = symp-
tom present; 2 = moderate symptom; and 3 = severe symptom) that
increase in intensity of depressive quality. Items are summed to pro-
duce a single depression summary score and somaticaffective and cog-
nitive factors. Further, percentile scores of 8590, 9195, N 95 are
indicative of mild, moderate and severe depression, respectively.
2.4.2.3. State-Trait Inventory form Y (STAI-Y), [28]. The state-trait anxiety
inventory (STAI-Y) is a self-report assessment instrument that permits a
distinction between existing anxiety (STAI-Y1) and predisposition to an
anxious reaction as a personality characteristic (STAI-Y2). Each scale is
composed of 20, four-point Likert items with responses related to
terms of intensity (from almost never to almost always). Scores for
both the STAI-Y1 and the STAI-Y2 can vary from a minimum of 20 to a
maximum of 80. Scores of 4050, 5160, N 60 are indicative of mild,
moderate and severe anxiety disorder, respectively.
2.5. Data analysis
Quantitative data are presented as mean standard deviation (SD),
while categorical data are summarized by absolute and percentage fre-
quencies. Due to potential violations of normality and/or homoscedas-
ticity assumptions, comparisons between independent groups of
subjects (i.e., ETPKUs vs HCs; ETPKUs with good vs poor IDC) compared
to quantitative variables were performed using nonparametric Mann
Whitney U test; Fisher's exact probability test was used for categorical
variables. Correlation between quantitative variables was estimated by
Spearman's correlation coefcient. Statistical analyses were performed
using STATA Statistical Software (Release 8.1).
3. Results
3.1. Psychiatric assessment
Seventeen out of 46 ETPKU patients (37%) met criteria for a psychi-
atric diagnosis [(10 females, 7 males), (8 CPKU; 7 MPKU; 2 mild HPA)].
The psychiatric diagnosis included the following: generalized anxiety
disorder (GAD, n = 7); depressive disorder (DP, n = 4); personality dis-
order (PD, n = 3); specic phobia (SP, n = 2); selective mutism (SM,
n = 1) (Table 1). Ten ETPKU with a psychiatric diagnosis were referred
to the psychiatric service. However, only 5 patients accepted and
followed the psychiatric therapeutic indications.
Of these 17 patients only four were on sapropterin adjunctive treat-
ment (15 mg/kg) and they all started the pharmacological therapy be-
fore 8 years of age while the onset of the symptomatology was
between 9.3 and 13.2 years of age.
ETPKU patients were divided in subgroups, based on age or quality
of metabolic control. When ETPKU patients were divided into two age
groups (b21 years of age vs 21 years of age; n = 21 and 28, respective-
ly), the two subgroups were different with regard to the presence of di-
agnosis, with younger patients showing a higher frequency of
psychiatric disorders (10/18 = 56%) than older patients (7/28 = 25%;
difference between younger and older patients = 31%, 95%CI with con-
tinuity correction = 0.01 to 0.56), although this difference was not
quite statistically signicant (Fisher's exact p = .060). The distribution
of categorical diagnosis was signicantly different between the two sub-
groups (Fisher's exact p = .001), with Anxiety Disorder diagnosis more
frequent in the younger group (9 out of 10 diagnosis) while Depressive
and Personality Disorders were more, or only, present in the older (3 out
of 7 for each diagnostic group) (Table 1).
When patients were divided into three age groups (b 21 years of age,
21 and b26 years of age, and 26; n = 18, 13, and 15, respectively), the
distribution of diagnosis was signicantly different between groups
(Fisher's exact p = .006): 10/18 (56%), 6/13 (46%) and 1/15 (7%)
were suffering from a psychiatric disorder in the b21 years, 21 and
b26 years and 26 groups, respectively.
When patients were divided into two subgroups according to the
quality of metabolic control in the rst 11 years of life (good =
 F. Manti et al. / Molecular Genetics and Metabolism 117 (2016) 1218
500 M vs a poor = N500 M; n = 28 and 18, respectively), patients
with good metabolic control showed higher frequency of psychiatric di-
agnosis than patients with poor metabolic control (14/28 = 50% vs 3/
18 = 17%, respectively; Fisher's exact p = .0300).
Twenty-ve ETPKU patients (54%) reported scores above the respec-
tive cut-off values for clinically relevant symptoms on at least one scale
of the psychiatric assessment (ASEBA, BDI-II, STAI-Y). The ETPKU pa-
tients showed signicantly higher scores for ASEBA Anxious/Depressed
(p = .0046), Withdrawn (p = .0002), Attention problems (p = .0185),
Aggressive behavior (p = .0044), Rule-breaking behavior (p = .0083), In-
ternalizing (p = .0175), Externalizing (p = .0108) and Total problems
(p = .0076) subscales compared to those of HCs (Table 2). Compared
to HC subjects, ETPKU patients reported more depressive symptoms,
as shown by the signicantly higher somaticaffective BDI-II domain
score (p = .0102) and the higher, although not quite signicant, BDI-II
total score (p = .0572), and signicantly higher anxiety symptoms as
shown by STAI-Y1 (p b .0001) and STAI-Y2 scales (p = .0001) (Table 3).
Gender analysis did not disclose any difference between females and
males ETPKU scores for all the submitted tests.
Of the 17 ETPKU patients suffering from a categorical psychiatric dis-
order 16 also reported clinical scores on at least one scale of the submit-
ted questionnaires. Conversely, eight patients scored above the
threshold for clinically relevant symptoms without fullling the criteria
for a psychiatric diagnosis. Twenty-one ETPKU patients (46%) did not
report clinical scores on the scales or psychiatric diagnosis. To evaluate
the agreement between clinical diagnosis and self-report data, we cal-
culated the percentage of concordant classications in the overall
group of subjects and in PKU subjects, separately. Specically, we com-
pared (i) the diagnosis of Anxiety Disorder (yes vs not) with the scores
(mild/moderate/severe vs normal) of STAIY1, STAIY2, and Anxious/De-
pressed, Withdrawn, Somatic complaints, Internalizing, Total problems,
subscales of ASEBA; (ii) the diagnosis of a Personality Disorder with the
score of Total problems subscale of ASEBA; (iii) the diagnosis of a De-
pressive Disorder with the scores of BDI-II (total score, somatic-
affective and cognitive domains), and Anxious/Depressed, Internalizing,
Total problems, Depressive mood, Somatic complaints subscales of
ASEBA. The overall agreement between clinical diagnosis and self-
report data ranged from 79% to 96% in the overall group of subjects
and from 65% to 93% in PKU patients, for all variables except for STAYI1T
and STAIY2T, where the concordance was always less than 50%. The
Negative Predictive Value (NPV) of self-report data was higher than
86% in all subjects and higher than 77% in PKU patients, while the Posi-
tive Predictive Value (PPV) was less than 40% for all variables, except So-
matic complaints subscale of ASEBA with respect to anxiety (PPV =
67%), and Total problems subscale of ASEBA with respect to either Per-
sonality Disorder or Depressive Disorder (PPV = 50% for both).
The 29 ETPKU patients without a categorical psychiatric disorder still
showed signicantly higher scores on Withdrawn (p = 0.0168), Rule-
breaking behavior (p = .0363) subscales of ASEBA, and STAI-Y1 (p =
.0037) and STAI-Y2 (p = .0015), when compared to HCs.
Turning to HC subjects, 7 out of 30 (20%) scored above the clinical
cut-off on one or more subscales of the psychiatric assessment
(ASEBA, BDI-II, STAI-Y), but none of them presented a categorical psy-
chiatric disorder.
No relationship was found between variability of Phe (SD Phe), de-
mographic characteristics, school level, and severity of psychiatric
symptoms. No signicant differences between employed and unem-
ployed patients have been found in the mean scores of all the submitted
self-report questionnaires and in the frequency of scores above the clin-
ical cut-off and psychiatric disorders.
3.2. Cognitive performance
IQ of ETPKU patients ranged from 75 to 124 (M = 92.72; SD =
13.11) and IQ for HCs ranged from 90 to 131 (M = 107.53; SD =
10.02), thus all IQs were within the normal range. Compared with
15
HCs, mean IQ of ETPKU was signicantly lower (p b 0.0001). In ETPKU
patients IQ score appeared to be weakly negatively related to the quality
of IDC from 11 to 44 years, although the correlation coefcient was not
quite statistically signicant (r = .2684, p = .0713).
The IQ of ETPKU patients suffering from a psychiatric disorder (M =
91.94; SD = 14.22) was not different from the IQ of patients who did
not have psychiatric disorders (M = 93.17, SD = 12.64; p = 0.381).
No correlation was found between the psychiatric assessment scores
and IQ. However, when compared to patients with IQ 85 (n = 29), pa-
tients with IQ b 85 (n = 17) showed higher scores on the somaticaffec-
tive factor of BDI-II (M = 56.88, SD = 24.63 vs M = 42.72, SD = 23.54;
difference M = 14.16, SE = 7.31, 95% CI = 0.58 to 28.90, p = .0546),
on the Withdrawn (M = 60.71, SD = 8.53 vs M = 57.24, SD = 9.68; dif-
ference M = 3.46, SE = 2.83, 95%CI = 2.25 to 9.18, p = .0618) and
Though Problems (M = 54.12, SD = 5.13 vs M = 50.69, SD = 10.34; dif-
ference M = 3.43, SE = 2.69, 95%CI = 2.00 to 8.85, p = .0644) sub-
scales of ASEBA. All these differences, although not quite statistically
signicant, indicated a trend consistent with other signicant effects.
With regard to patients with good life-long metabolic control
( 500 M; n = 14), patients with poor metabolic control (N500 M;
n = 32) showed a lower IQ (M = 90.03, SD = 11.12 vs M = 98.86,
SD = 15.54 in poor vs good metabolic control patients, respectively; dif-
ference M = 8.83, SE = 4.03, 95% CI = 16.95 to 0.70), although
this difference did not quite achieve statistical signicance in the non-
parametric test (p = .0874).
4. Discussion
Since 1980 many studies have investigated psychiatric symptoms in
PKU patients. The rst most commonly described symptoms were hy-
peractivity, aggressiveness and externalizing problems in general. How-
ever the samples also included patients with intellectual disability [10,
29] and externalizing problems are typically associated with such a con-
dition [30]. Thereafter dietary recommendations changed toward an
earlier and longer restriction of Phe intake, which was associated whit
the change in symptoms reported by patients in favor of internalizing
symptoms.
Compared with their peers, ETPKU children were reported to exhibit
an excess of sadness, fear, phobias, feeling of being different, low self-
esteem, withdrawn and lack of autonomy [10]. Other authors reported
in children [11,3132] and young adolescents PKU [12,14,3234] de-
pressive mood, anxiety, physical complaints or social isolation. Depres-
sive mood and anxiety are also the most frequently described
symptoms in ETPKU adults [8,1820,22,35]. These studies converged
on an overall pattern of internalizing symptoms [10,18,36] even though
not all the research revealed psychiatric problems [3740]. Most of the
above mentioned results were based on parent and teacher behavior
ratings, questionnaires and psychometric personality inventories, mak-
ing it difcult to evaluate the severity and the clinical relevance of the
symptoms described.
Patients enrolled in the present study were asked to ll in self-
reported questionnaires and further underwent a clinical psychiatric
evaluation, to establish the relevance in the daily-life functioning of
the reported symptoms. We investigated ETPKU patients with well-
documented blood Phe levels since the time of birth. We examined IQ
and psychiatric symptoms in relation to various indices of Phe control
reecting average Phe (IDCs) and Phe uctuations (SD Phe) in different
epochs of development.
Results from our study conrm the suboptimal emotional and be-
havioral outcome in adolescent and adult ETPKU patients, who were
found to report high rates of psychiatric internalizing symptoms (anxi-
ety, depressive mood and phobias) compared to healthy peers. Remark-
ably 37% of the ETPKU patients (17 out of 46) also met criteria for a
psychiatric diagnosis according to the DSM-5. As regards vulnerability
psychiatric assessment ETPKU patients reported more frequent psychi-
atric symptoms such as anxiety, depression, withdrawal, attention
16 F. Manti et al. / Molecular Genetics and Metabolism 117 (2016) 1218

Table 2
Clinical results of ASEBA Scales and IQ.

Test ETPKU (N = 46) n HCs (N = 30) n (ETPKU HCs) % Difference 95% CI MannWhitney
M(SD) M(SD) M(SE) 95% CI P value

IQ 92.72 (13.11) 107.53 (10.02) 14.82 (2.81) 20.42 to 9.21 0.0000

ASEBA Scales
Youth Self Report
Adult Self Report
Anxious/depressed T-score 57.57 (8.36) 52.07 (2.76) 5.50 (1.58) 2.34 to 8.65 0.0046
Score N70 5 0 11% 5% to 24%
Withdrawn T-score 58.52 (9.33) 52.30 (3.54) 6.22 (1.79) 2.66 to 9.78 0.0002
Score N70 3 0 7% 8% to 19%
Somatic complaints T-score 53.33 (5.44) 52.20 (4.02) 1.13 (1.16) 1.18 to 3.43 0.2964
Score N70 1 0 2% 12% to 13%
Thought problems T-score 51.96 (8.87) 50.80 (2.86) 1.16 (1.68) 2.19 to 4.50 0.0624
Score N70 1 0 2% 12% to 13%
Attention problems T-score 55.09 (5.90) 52.07 (3.69) 3.02 (1.21) 0.61 to 5.43 0.0185
Score N70 1 0 2% 12% to 13%
Aggressive behavior T-score 54.15 (6.21) 51.03 (2.48) 3.12 (1.19) 0.74 to 5.50 0.0044
Score N70 1 0 2% 12% to 13%
Rule-breaking behavior T-score 52.22 (3.23) 51.03 (2.48) 1.18 (0.69) 0.20 to 2.57 0.0083
Score N70 0 0
Internalizing T-score 53.78 (11.20) 47.67 (5.94) 6.12 (2.23) 1.68 to 10.55 0.0175
Score N70 4 0 9% 7% to 22%
Externalizing T-score 48.00 (8.98) 41.80 (10.42) 6.20 (2.25) 1.73 to 10.67 0.0108
Score N70 1 0 2% 12% to 13%
Total problems T-score 49.04 (10.53) 42.80 (7.79) 6.24 (2.24) 1.78 to 10.71 0.0076
Score N70 1 0 2% 12% to 13%

Legend: ETPKU = early treated PKU; HCs = healthy controls; M = mean; SD = standard deviation; SE = standard error; CI = condence interval;
p b 0.05.
p b 0.01.

problems, aggressive/rule-breaking behavior as assessed by adminis- reported clinical scores in the attention problems, aggressive behavior
tered self-reported questionnaires compared to HCs. Despite the statis- and externalizing problems. In contrast to the results of Stemerdink
tically signicant difference in the reported symptoms, ETPKU patients and coworkers [33], but in line with other authors [10,1314,37], we
scored in the pathological range especially in the internalizing domains. did not nd a different rate of psychiatric symptoms between male
Only one patient, who was diagnosed as suffering a PD (see Table 2), and female PKU patients.
Turning to the categorical psychiatric assessment, adolescent ETPKU
patients were mainly suffering from Anxiety Disorders while young
Table 3
Results of BDI-II and STAI-Y questionnaires. adult patients from Depressive and Personality Disorders, while only
one adult patient met criteria for a clinical psychiatric diagnosis, sug-
Test ETPKU (N HCs (N (ETPKU Difference Mann
gesting the hypothesis of a different psychiatric vulnerability through-
= 46) = 30) HCs) 95% CI Whitney
P value out life, as found also in the context of neurocognitive functions [41].
M(SD) M(SD) M(SE)
A few studies revealed associations between behavioral symptoms
BDI-II total score 48.00 37.00 11.00 0.63 to 0.0572
and metabolic control but different indices of metabolic control were
(percentile) (26.30) (22.46) (5.83) 22.63
Score 8590 3 2 used. Specically, mean Phe level in the two years preceding the assess-
Score 9195 0 0 ment were positively correlated with the occurrence of psychiatric
Score N95 2 0 symptoms [8]; concurrent Phe levels, in PKU patients younger than
BDI II 47.96 33.83 14.12 3.59 to 0.0102 18 years of age, were correlated with behavioral/mental health prob-
somaticaffective (24.66) (18.74) (5.29) 24.66
factor
lems [42]. Ten Hoedt and coworkers [20] reported in a randomized,
Score 8590 2 1 double-blind, placebo-controlled study that high Phe levels were associ-
Score 9195 1 0 ated with the feeling of being more depressed, more fatigued, and less
Score N95 2 0 vigorous, highlighting the short-term negative effect of Phe on mood.
BDI-II cognitve 61.89 55.60 6.29 2.64 to 0.1450
Several other studies, conversely, could not nd a correlation be-
factor (19.72) (18.12) (4.48) 15.23
Score 8590 1 0 tween the severity of psychiatric symptoms and biochemical markers
Score 9195 2 3 [8,11,14,43]. In line with these studies we did not nd a signicant rela-
Score N95 2 0 tionship between biochemical markers and symptoms scale/subscale
STAI-Y state 48.17 39.40 8.77 4.72 to b0.0001 scores or psychiatric diagnosis.
(9.25) (7.70) (2.04) 12.83
Taking into consideration the fact the PKU is a chronic disease that
Score 4050 9 2
Score 5160 5 2 requires adherence to a restricted dietetic regimen and routine visits
Score N60 3 0 at the specialized metabolic center, Weglage and colleagues [11] com-
STAI-Y trait 48.70 39.20 9.50 4.75 to 0.0001 pared patients with PKU and diabetes mellitus. Both groups of patients
(11.01) (8.62) (2.38) 14.24
disclosed higher rates of internalizing problems such as depressive
Score 4050 9 3
Score 5160 9 2 mood, anxiety, physical complaints or social isolation, compared to a
Score N60 4 0 control group. Conversely, externalizing problems were not different
Legend: ETPKU = early treated PKU; HCs = health controls.
from those of healthy controls. Thereafter PKU patients were also com-
p b 0.05. pared to patients with congenital hypothyroidism [44]. Researchers re-
p b 0.01. ported higher rates of internalizing symptoms in both groups, which
 F. Manti et al. / Molecular Genetics and Metabolism 117 (2016) 1218
were related to parental maladjustment and with maladaptive coping
strategies.
Supporting the hypothesis that the burden of the strict follow-up
and the dietary treatment determines a psychological stress for children
and their families surprisingly we found that patients who followed the
dietary recommendations during the rst decade of life better suffered
more frequently from a psychiatric disorder compared to those patients
with poor metabolic control. Another hypothesis is that patients (and
their families) who better followed dietary recommendations are
more self-aware, and this might determine the proneness of developing
anxiety and depression symptoms.
Suboptimal cognitive outcome in ETPKU patients, which is inu-
enced by the quality of metabolic control is widely reported in the liter-
ature [4547] and conrmed in our sample. No correlations were
observed between IQ and psychiatric vulnerability assessment scores,
however ETPKU patients with lower IQ (b 85) showed some proneness
to internalizing symptoms. Cognitive fragility in known to increase the
incidence of psychiatric symptoms [30] and this is also conrmed in
ETPKU patients.
Taking all these results together, the presence of emotional and be-
havioral problems in PKU patients might reect the consequences of
growing-up and living with an imperceptible as well as compelling/con-
strictive chronic disease.
The main limitations of the present study are: patients and HCs are
not matched for IQ; the sample size does not allow us to draw different
psychopathological proles according to the sex.
5. Conclusion
ETPKU patients suffer from a high rate of psychiatric disorders that
might be a limiting factor for optimal adaptive behavior in their
everyday-life. The occurrence of intellectual impairment due to the
quality of the dietary control may potentially amplify the burden of
the dietary treatment and as such increase the psychiatric vulnerability
of these patients. Further studies are mandatory in order to explore if
neuromediators alteration or other biological determinants may have
a part in determining the psychiatric disorders of PKU subjects.
References
[1] J.J. Mitchell, Y.J. Trakadis, C.R. Scriver, Phenylalanine hydroxylase deciency, Genet.
Med. 13 (2011) 697707.
[2] E. Schmidt, A. Rupp, P. Burgard, J. Pietz, J. Weglage, L. de Sonneville, Sustained atten-
tion in adult phenylketonuria: the inuence of the concurrent phenylalanine-blood
level, J. Clin. Exp. Neuropsychol. 16 (1994) 681688.
[3] J.E. Sullivan, P. Chang, Review: emotional and behavioral functioning in phenylke-
tonuria, J. Pediatr. Psychol. 24 (1999) 281299.
[4] S.C. Huijbregts, L.M. de Sonneville, R. Licht, F.J. Van Spronsen, P.H. Verkerk, J.A.
Sergeant, Sustained attention and inhibition of cognitive interference in treated
phenylketonuria: associations with concurrent and lifetime phenylalanine concen-
trations, Neuropsychologia 40 (2002) 715.
[5] S.C. Huijbregts, L.M. de Sonneville, R. Licht, F.J. Van Spronsen, J.A. Sergeant, Short-
term dietary interventions in children and adolescents with treated phenylketon-
uria: effects on neuropsychological outcome of a well-controlled population, J. In-
herit. Metab. Dis. 25 (2002) 419430.
[6] S.E. Christ, S.C.J. Huijbregts, L.M.J. de Sonneville, D.A. White, Executive function in
early-treated phenylketonuria: prole and underlying mechanisms, Mol. Genet.
Metab. 99 (2010) S22S32.
[7] V.L. Brumm, D. Bilder, S.E. Waisbren, Psychiatric symptoms and disorders in phenyl-
ketonuria, Mol. Genet. Metab. 99 (2010) S59S63.
[8] D.A. Bilder, B.K. Burton, H. Coon, L. Leviton, J. Ashworth, B.D. Lundy, et al., Psychiatric
symptoms in adults with phenylketonuria, Mol. Genet. Metab. 108 (2013) 155160.
[9] B.K. Burton, L. Leviton, H. Vespa, H. Coon, N. Longo, B.D. Lundy, et al., A diversied
approach for PKU treatment: routine screening yields high incidence of psychiatric
distress in phenylketonuria clinics, Mol. Genet. Metab. 108 (2013) 812.
[10] I. Smith, M.G. Beasley, O.H. Wolff, A.E. Ades, Behavior disturbance in 8-year-old chil-
dren with early treated phenylketonuria, J. Pediatr. 112 (1988) 403408.
[11] J. Weglage, M. Grenzebach, M. Pietsch, R. Feldmann, R. Linnenbank, J. Denecke, et al.,
Behavioural and emotional problems in early-treated adolescents with phenylke-
tonuria in comparison with diabetic patients and healthy controls, J. Inherit.
Metab. Dis. 23 (2000) 487496.
17
[12] R. Sharman, K. Sullivan, R.M. Young, J. McGill, Depressive symptoms in adolescents
with early and continuously treated phenylketonuria: associations with phenylala-
nine and tyrosine levels, Gene 504 (2012) 288291.
[13] G.M. Realmuto, B.D. Garnkel, M. Tuchman, M.Y. Tsai, P.N. Chang, R.O. Fisch, et al.,
Psychiatric diagnosis and behavioral characteristics of phenylketonuric children, J.
Nerv. Ment. Dis. 174 (1986) 536540.
[14] P. Burgard, M. Armbruster, E. Schmidt, A. Rupp, Psychopathology of patients treated
early for phenylketonuria: results of the German collaborative study of phenylke-
tonuria, Acta Paediatr. 407 (1994) 108110.
[15] A.F. Angelino, A. Bone, A.K. Kuehl, A neuropsychiatric perspective of phenylketon-
uria II: needs assessment for a psychiatric presence, Psychosomatics 53 (2012)
541549.
[16] A. Bone, A.K. Kuehl, A.F. Angelino, A neuropsychiatric perspective of phenylketon-
uria I: overview of phenylketonuria and its neuropsychiatric sequelae, Psychoso-
matics 53 (2012) 517523.
[17] J. Weglage, B. Fnders, B. Wilken, D. Schubert, E. Schmidt, P. Bergard, et al., Psycho-
logical and social ndings in adolescents with phenylketonuria, Eur. J. Pediatr. 151
(1992) 522525.
[18] J. Pietz, B. Ftkenheuer, P. Burgard, M. Armbruster, G. Esser, H. Schmidt, Psychiatric
disorders in adult patients with early treated phenylketonuria, Pediatrics (1997)
345350.
[19] V.L. Brumm, C. Azen, R. Moats, A. Stern, C. Broomand, M. Nelson, Neuropsychological
outcome of subjects participating in the PKU Adult Collaborative Study: a prelimi-
nary review, J. Inherit. Metab. Dis. 27 (2004) 549566.
[20] A.E. Ten Hoedt, L.M. de Sonneville, B. Francois, N.M. ter Horst, M.C. Janssen, M.E.
Rubio-Gozalbo, et al., High phenylalanine levels directly affect mood and sustained
attention in adults with phenylketonuria: a randomized, double-blind, placebo con-
trolled crossover trial, J. Inherit. Metab. Dis. 34 (2011) 165171.
[21] M.D. Ris, S.E. Williams, M.M. Hunt, H.K. Berry, N. Leslie, Early-treated phenylketon-
uria: adult neuropsychologic outcome, J. Pediatr. 124 (1994) 388392.
[22] R. Koch, B. Burton, G. Hoganson, R. Peterson, W. Rhead, B. Rouse, et al., Phenylketon-
uria in adulthood: a collaborative study, J. Inherit. Metab. Dis. 25 (2002) 333346.
[23] N. Blau, F.J. van Spronsen, H.L. Levy, Phenylketonuria, Lancet 376 (2010) 14171427.
[24] D. Wechsler, Wechsler intelligence scale for children III (WISC-III), New York, The
Psychological Corporation, 1991. Italian version, A. Orsini, L. Picone, Scala di
intelligenza Wechsler per bambini- terza edizione, Organizzazioni Speciali, Firenze,
2006.
[25] D. Wechsler, Wechsler adult intelligence scale- revised (WAIS-R), New York, The
Psychological Corporation, 1981. Italian version, C. Laicardi, A. Orsini, Scala di
intelligenza Wechsler per adulti, Organizzazioni Speciali, Firenze, 1997.
[26] T.M. Achenbach, L. A. Rescorla, Manual for the ASEBA School-Age Forms and Proles.
Burlington, VT: University of Vermont, Research Center for Children, Youth, and
Families, 1991. Italian version, A. Frigerio, Istituto Scientico E. Medea, Associazione
La Nostra Famiglia, Bosisio Parini, Lecco, 2001.
[27] A. T. Beck, R. A. Steer, G. K. Brown, Beck Depression Inventory, Second ed., The Psy-
chological corporation, San Antonio, Texas, 1996. Italian version, M. Ghisi, G. B.
Flebus, A. Montano, E. Sanavio, C. Sica, Organizzazioni Speciali, Firenze, 2006.
[28] C.D. Spielberg, R.L. Gorsuche, R.E. Lushene, The state trait anxiety inventory: test
manual, Consulting Psychologist Press, Palo Alto (CA), 1970. Italian version, L.
Pedrabissi, M. Santinello, Organizzazioni Speciali, Firenze, 1996.
[29] N.A. Holtzman, R.A. Kronmal, W. van Doorninck, C. Azen, R. Koch, Effect of age at loss
of dietary control on intellectual performance and behavior of children with phenyl-
ketonuria, N. Engl. J. Med. 314 (1986) 593598.
[30] J.W. Jacobson, Problem behavior and psychiatric impairment within a developmen-
tally disabled population I: behavior frequency, Appl. Res. Ment. Retard. 3 (1982)
121139.
[31] W. Wu, D. Sheng, J. Shao, Z. Zhao, Mental and motor development and psychosocial
adjustment of Chinese children withphenylketonuria, J. Paediatr. Child Health 7
(2011) 441447.
[32] S. Cappelletti, G. Cotugno, B.M. Goffredo, R. Nicol, S.M. Bernabei, S. Caviglia, V. Di
Ciommo, Cognitive ndings and behavior in children and adolescents with phenyl-
ketonuria, J. Dev. Behav. Pediatr. 34 (2013) 392398.
[33] B.A. Stemerdink, A.F. Kalverboer, J.J. van der Meere, M.W. van der Molen, J. Huisman,
L.W. de Jong, et al., Behaviour and school achievement in patients with early and
continuously treated phenylketonuria, J. Inherit. Metab. Dis. 23 (2000) 548562.
[34] K. Anjema, M. van Rijn, P.H. Verkerk, J.G. Burgerhof, M.R. Heiner-Fokkema, F.J. van
Spronsen, PKU: high plasma phenylalanine concentrations are associated with in-
creased prevalence of mood swings, Mol. Genet. Metab. 104 (2011) 231234.
[35] M. Bik-Multanowski, B. Didycz, R. Mozrzymas, M. Nowacka, L. Kaluzny, W. Cichy,
et al., Quality of life in noncompliant adults with phenylketonuria after resumption
of the diet, J. Inherit. Metab. Dis. 31 (2008) S415S418.
[36] R.O. Fisch, P.N. Chang, S. Weisberg, P. Guldberg, F. Gttler, M.Y. Tsai, Phenylketonuric
patients decades after diet, J. Inherit. Metab. Dis. 18 (1995) 347353.
[37] J. Weglage, A. Rupp, E. Schmidt, Personality characteristics in patients with phenyl-
ketonuria treated early, Pediatr. Res. 35 (1994) 611613.
[38] P. Grifths, M. Tarrini, P. Robinson, Executive function and psychosocial adjustment
in children with early treated phenylketonuria: correlation with historical and con-
current phenylalanine levele, J. Intellect. Disabil. Res. 41 (1997) 317323.
[39] J.E. Sullivan, Emotional outcome of adolescents and young adults with early and
continuously treated phenylketonuria, J. Pediatr. Psychol. 26 (2001) 477484.
[40] M.A. Landolt, J.M. Nuoffer, B. Steinmann, A. Superti-Furga, Quality of life and psycho-
logic adjustment in children and adolescents with early treated phenylketonuria
can be normal, J. Pediatr. 140 (2002) 516521.
[41] V. Leuzzi, D. Mannarelli, F. Manti, C. Pauletti, N. Locuratolo, C. Carducci, et al., Age-
related psychophysiological vulnerabilit to phenylalanine in phenylketonuria,
Front. Pediatr. 2 (2014) 57.
18 F. Manti et al. / Molecular Genetics and Metabolism 117 (2016) 1218
[42] R. Jahja, S.C. Huijbregts, L.M. de Sonneville, J.J. van der Meere, A.M. Bosch, C.E. Hollak,
et al., Mental health and social functioning in early treated Phenylketonuria: the
PKU-COBESO study, Mol. Genet. Metab. 110 (2013) S57S61.
[43] M.D. Ris, A.M. Weber, M.M. Hunt, H.K. Berry, S.E. Williams, N. Leslie, Adult psycho-
social outcome in early-treated phenylketonuria, J. Inherit. Metab. Dis. 20 (1997)
499508.
[44] R. Jusiene, V. Kucinskas, Psychological adjustment of children with congenital hypo-
thyroidism and phenylketonuria as related to parental psychological adjustment,
Medicina (Kaunas) 40 (2004) 663670.
[45] J.J. Moyle, A.M. Fox, M. Arthur, M. Bynevelt, J.R. Burnett, Meta-analysis of neuropsy-
chological symptoms of adolescents and adults with PKU, Neuropsychol. Rev. 17
(2007) 91101.
[46] S.E. Waisbren, K. Noel, K. Fahrbach, C. Cella, D. Frame, A. Dorenbaum, H. Levy, Phe-
nylalanine blood levels and clinical outcomes in phenylketonuria: a systematic liter-
ature review and meta-analysis, Mol. Genet. Metab. 92 (2007) 6370.
[47] F. Nardecchia, F. Manti, F. Chiarotti, C. Carducci, C. Carducci, V. Leuzzi,
Neurocognitive and neuroimaging outcome of early treated young adult PKU pa-
tients: a longitudinal study, Mol. Genet. Metab. 115 (2015) 8490.