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Abnormal movements in nver medicated elderly indian patients with schizophrenia
Abnonnal movements in never-medicated schizophrenics
48. Abnormal movements in never-medicated schizophrenics 148-1
I schizophrenia Extrapyramidal signs In dyskinesia In first episode
Jeffrey Ueberman, AnJan Chatte~ee, Miranda Chakos, Amy Koreen, stephen Geisler, Brian Shellman, Margaret Woemer, John M. Kane, Jose A1vir. Department of Psychiatry, University of North Carolina, Chapel Hill, NCo USA The question of whether extrapyramidal signs in dyskinesia are idiopathic or dnJg Induced has been a long standing issue of controversy In schizophre• nia. We have conducted a prospective longitudinal study of first episode IChiZOPhrenia. The sample includes 118 patients ascertained In their first episode. most of whom were treatment naive and followed for up to five years. The results Indicate that the prevalence of spontaneous or pretreat• ment EPS and dyskinesia is quite low, but that these signs are associated with poor trealment response and long term outcome. These results will be presented in detail and discussed.
148-21 disease 'Tardive' dyskinesia and Its relationship to the process of schizophrenia J.L Waddington, E. O'Caliaghan, C. Larkin, D. Meagher, J. Quinn, J. Mullaney. Department of Clinical Pharmacology. Royal College of SutpeOflS In Ireland. Dublin, Ireland New evidence sustains and elaborates our earlier proposition that in IehizOPhrenla the contribution of spontaneous disease-related Involuntary movements to the totality of 'tardive' dyskinesia In neuroleptic-treated pop• . .tionS has been seriously underestimated and that predisposition to such mov,ment disorder Is related to clinical features of the Illness (Waddington, 1989). Forty-S8Ven younger outpatients with schizophrenia were examined for 'lardlve' dyskinesia; they were examined also for minor physical anomalies and neuropsychological test performance. Cortical atrophy, signal hyper• W1lenSlties and tateral ventricular volume were determined on magnetic monance imaging (Waddington et al., 1995). Patients with and without tatdlve dyskinesia could not be distingUished by age, gender distribution or • numbeI' of clinical measures; however, patients with tardive dyskinesia eorted fewer categories on the Wisconsin Card Sorting Test (P = 0.04). (;erebra/ strueture in patients with and without tardive dyskinesia could not be distinguished on magnetic resonance Imaging but those with dyskinesia, .. of whom showed involvement of the orofaclal region, showed more evi• dent minor physical anomalies of the head relative to those of the periphery (p 0 02). 'Tardive' orofaclal dyskinesia In schizophrenia appears to be ...:a~ted particularly with poorer frontal lobe function, while predominance or craniofacial dysmorphogenesls may constitute a vulnerability factor that II related to the early origins of the disease process. More basic cognitive tunction was assessed at initial and at 5- and 1O-year follow-up assess• ments among 41 primarily older Inpatients manifesting the severest form of IChiZOP/lrenia; additionally, the presence and severity of 'tardive' dyskinesia was evaluated on each occasion (Waddington & Youssef, 1996). Longltudl· ~ patients with persistent 'tardive' orofacial dyskinesia continued to show ~ cognitlve function than those consistently without such movement ::.c,e~ thOUgh within neither group did cognitive function change over the clecad8.'ThOse patients demonstrating prospectively the emergence of oro• facial dyskinesia showed a marked deterioration in their cognitive function over the same time-frame within which their movement disorder emerged, IlIA this decline did not progress further thereafter. There appears to exist some modest, progressive deterioration in cognitive function even late In !he chronic phase of severe schizophrenic illness which appears to derive primarily from patients showing de nollO emergence of 'tardive' orofaclal dyskinesia. The literature suggests that the prevalence of Involuntary movements at the first psychotiC episode Is very low while in our ongoing studies on elderly ~ents having decades of illness and antipsychotic therapy, prevalence II d the order of 90%. Involuntary movements emerging during long-term anlipsychOtlc therapy appear to be a drug-enhancement of dyskinesia that II related to features of the Illness for which that treatment was prescribed; wlnerability to such movement disorder, rooted intimately in the disease
BIOL. PSYCHIATRY 1997;42: 18-297S
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process of schizophrenia, may approach 100% over a lifetime of severe, medicated Illness. These studies were supported by the Health Research Board. References (1) Waddington J.L. (19B9) Schizophrenia, allecllva psychoses, and other disorders treated with neuroleptic drugs: the enigma of tardive dyskinesia, ns neurobiological determinants, and the conflict of paradigms. Int Rev Neuroblol31: 297-353. [2J Waddington J.L, Youssef H.A. (1996) CognlUve dysfunction In chronIC schizophrenia followed prospectively over 10 years and Its longnudlnal relationship to the emer• gence of tardive dyskinesia. Psychol Med 26: 681 ~B8. [3J Waddington J.L, O'Caliaghan E., Buckley P., Madigan C., Redmond 0., Stack J.P., Kinsella A., Larkin C., Ennis J.T. (1995) Tardive dyskinesia In SChizophrenia: relation• ship to minor physical anomalies, frontal lobe dysfunction and cerebral structure on magnetIC resonance Imaging. Br J Psychiatry 167: 4144.
148-31 Abnormal movements In never medicated elderly Indian patients with schizophrenia R.G. McCreadie, R. Thara. Crichfon Royal Hospital, Dumfries, Scotland, UK ObJectives: Historical records suggest dyskinesia was observed In severely ill institutionalised patients with schizophrenia In the pre-neuroleptic era. More recent work has not found dyskinesia in never-medicated younger and middle aged patients. The present study complements this recent work and avoids the confounders of severity of illness and Institutionalism by examining elderly patients In a wide variety of community settings. Methods: Movement disorders were examined In 308 elderly Individuals In Madras, India, using the Abnormal Involuntary Movements Scale, the Simpson and Angus Parkinsonism Scale and the Bames Akathlsia Scale. Patients' mental state was assessed by the Positive and Negative Syndrome Scale. Results: Dyskinesia was found In 15% of normal subjects (n .. 101, mean age 63 years), 15% of first degree blood relatives of younger schizophrenic patients (n =103, mean age 63 years), 38% of never medicated patients (n 21, mean age 65 years) and 41% of medicated patients (n. 83, mean age 57 years). The respective prevalences for Parkinsonism were 6%, 11%, 24% and 36%; and for akathisia 9%, 5%, 21% and 23%. Dyskinesia was associated with negative schizophrenic symptoms. Conclusions: Dyskinesia In elderly schizophrenic patients Is an Integral part of the illness and not associated with antipsychotic medication.
=
148-41 Abnormal Involuntary movements In never medicated schizophrenic patients N. Kadri ' , D. Fenn 2, D. Moussaoul', C. Green 2, A. Tilane', B. Bentounsl 1 , D. Casey 2, W. Hoffman 2. 1 University Psychiatric Center Ibn Rushd, Casablanca, Morocco, USA, 2 Department of Psychiatry, VA Medical Center, Portland, Oregon, USA It has been assumed for the past 40 years that tardive dyskinesia (TO) Is due to neuroleptics only. A medico-legal consequence was that, in the United States, during the eighties, some patients suffering from TO received up to two million dollars compensation from courts. An Important question remains unanswered: does schizophrenia Itself represent a risk factor for these abnormal movements? In other words, do spontaneous abnormal movements exist In never medicated schizophrenic patients, and do they represent part of the clinical picture of this Illness? A few studies have been conducted in this field In the world, due to the high difficulty to find never medicated schizophrenic patients in centers with the expertise of research in this field, especially In industrialized countries. In Casablanca, a number of studies have been conducted, some of them In collaboration with the Department of Psychiatry of Portland, Oregon, USA. Some preliminary results of the last ongoing study are: Methods. and patients: 80 never medicated schizophrenics (G1), 61 treated schizophrenics (G2), and 52 normal controls (G3) were included, matched for sex, age and duration of Illness for the groups of schizophrenic patients. The mean age for the 3 groups was similar (G1: 29.36 ± 6 years; G2: 29.34 ± 5.52 years; G3: 32 ± 7.94 years). The mean duration of Illness was also similar in the two groups of patients (G1: 5.36 ± 3.89 years; 02: 5.72 ± 3.96 years). DSM IV criteria were used for the diagnosis, the SCIO and the SCID-NP for the clinical interview, the PANSS for the clinical assessment, and the Abnormal Involuntary Movement Scale (AIMS) for the assessment of the movements. Each examination of the abnomnal movements was videotaped with two cameras, and assessed in two ways: open and blind.
48. Abnormal movements in never-medicated schizophrenics 148-1
I schizophrenia Extrapyramidal signs In dyskinesia In first episode
Jeffrey Ueberman, AnJan Chatte~ee, Miranda Chakos, Amy Koreen, stephen Geisler, Brian Shellman, Margaret Woemer, John M. Kane, Jose A1vir. Department of Psychiatry, University of North Carolina, Chapel Hill, NCo USA The question of whether extrapyramidal signs in dyskinesia are idiopathic or dnJg Induced has been a long standing issue of controversy In schizophre• nia. We have conducted a prospective longitudinal study of first episode IChiZOPhrenia. The sample includes 118 patients ascertained In their first episode. most of whom were treatment naive and followed for up to five years. The results Indicate that the prevalence of spontaneous or pretreat• ment EPS and dyskinesia is quite low, but that these signs are associated with poor trealment response and long term outcome. These results will be presented in detail and discussed.
148-21 disease 'Tardive' dyskinesia and Its relationship to the process of schizophrenia J.L Waddington, E. O'Caliaghan, C. Larkin, D. Meagher, J. Quinn, J. Mullaney. Department of Clinical Pharmacology. Royal College of SutpeOflS In Ireland. Dublin, Ireland New evidence sustains and elaborates our earlier proposition that in IehizOPhrenla the contribution of spontaneous disease-related Involuntary movements to the totality of 'tardive' dyskinesia In neuroleptic-treated pop• . .tionS has been seriously underestimated and that predisposition to such mov,ment disorder Is related to clinical features of the Illness (Waddington, 1989). Forty-S8Ven younger outpatients with schizophrenia were examined for 'lardlve' dyskinesia; they were examined also for minor physical anomalies and neuropsychological test performance. Cortical atrophy, signal hyper• W1lenSlties and tateral ventricular volume were determined on magnetic monance imaging (Waddington et al., 1995). Patients with and without tatdlve dyskinesia could not be distingUished by age, gender distribution or • numbeI' of clinical measures; however, patients with tardive dyskinesia eorted fewer categories on the Wisconsin Card Sorting Test (P = 0.04). (;erebra/ strueture in patients with and without tardive dyskinesia could not be distinguished on magnetic resonance Imaging but those with dyskinesia, .. of whom showed involvement of the orofaclal region, showed more evi• dent minor physical anomalies of the head relative to those of the periphery (p 0 02). 'Tardive' orofaclal dyskinesia In schizophrenia appears to be ...:a~ted particularly with poorer frontal lobe function, while predominance or craniofacial dysmorphogenesls may constitute a vulnerability factor that II related to the early origins of the disease process. More basic cognitive tunction was assessed at initial and at 5- and 1O-year follow-up assess• ments among 41 primarily older Inpatients manifesting the severest form of IChiZOP/lrenia; additionally, the presence and severity of 'tardive' dyskinesia was evaluated on each occasion (Waddington & Youssef, 1996). Longltudl· ~ patients with persistent 'tardive' orofacial dyskinesia continued to show ~ cognitlve function than those consistently without such movement ::.c,e~ thOUgh within neither group did cognitive function change over the clecad8.'ThOse patients demonstrating prospectively the emergence of oro• facial dyskinesia showed a marked deterioration in their cognitive function over the same time-frame within which their movement disorder emerged, IlIA this decline did not progress further thereafter. There appears to exist some modest, progressive deterioration in cognitive function even late In !he chronic phase of severe schizophrenic illness which appears to derive primarily from patients showing de nollO emergence of 'tardive' orofaclal dyskinesia. The literature suggests that the prevalence of Involuntary movements at the first psychotiC episode Is very low while in our ongoing studies on elderly ~ents having decades of illness and antipsychotic therapy, prevalence II d the order of 90%. Involuntary movements emerging during long-term anlipsychOtlc therapy appear to be a drug-enhancement of dyskinesia that II related to features of the Illness for which that treatment was prescribed; wlnerability to such movement disorder, rooted intimately in the disease
BIOL. PSYCHIATRY 1997;42: 18-297S
1355
process of schizophrenia, may approach 100% over a lifetime of severe, medicated Illness. These studies were supported by the Health Research Board. References (1) Waddington J.L. (19B9) Schizophrenia, allecllva psychoses, and other disorders treated with neuroleptic drugs: the enigma of tardive dyskinesia, ns neurobiological determinants, and the conflict of paradigms. Int Rev Neuroblol31: 297-353. [2J Waddington J.L, Youssef H.A. (1996) CognlUve dysfunction In chronIC schizophrenia followed prospectively over 10 years and Its longnudlnal relationship to the emer• gence of tardive dyskinesia. Psychol Med 26: 681 ~B8. [3J Waddington J.L, O'Caliaghan E., Buckley P., Madigan C., Redmond 0., Stack J.P., Kinsella A., Larkin C., Ennis J.T. (1995) Tardive dyskinesia In SChizophrenia: relation• ship to minor physical anomalies, frontal lobe dysfunction and cerebral structure on magnetIC resonance Imaging. Br J Psychiatry 167: 4144.
148-31 Abnormal movements In never medicated elderly Indian patients with schizophrenia R.G. McCreadie, R. Thara. Crichfon Royal Hospital, Dumfries, Scotland, UK ObJectives: Historical records suggest dyskinesia was observed In severely ill institutionalised patients with schizophrenia In the pre-neuroleptic era. More recent work has not found dyskinesia in never-medicated younger and middle aged patients. The present study complements this recent work and avoids the confounders of severity of illness and Institutionalism by examining elderly patients In a wide variety of community settings. Methods: Movement disorders were examined In 308 elderly Individuals In Madras, India, using the Abnormal Involuntary Movements Scale, the Simpson and Angus Parkinsonism Scale and the Bames Akathlsia Scale. Patients' mental state was assessed by the Positive and Negative Syndrome Scale. Results: Dyskinesia was found In 15% of normal subjects (n .. 101, mean age 63 years), 15% of first degree blood relatives of younger schizophrenic patients (n =103, mean age 63 years), 38% of never medicated patients (n 21, mean age 65 years) and 41% of medicated patients (n. 83, mean age 57 years). The respective prevalences for Parkinsonism were 6%, 11%, 24% and 36%; and for akathisia 9%, 5%, 21% and 23%. Dyskinesia was associated with negative schizophrenic symptoms. Conclusions: Dyskinesia In elderly schizophrenic patients Is an Integral part of the illness and not associated with antipsychotic medication.
=
148-41 Abnormal Involuntary movements In never medicated schizophrenic patients N. Kadri ' , D. Fenn 2, D. Moussaoul', C. Green 2, A. Tilane', B. Bentounsl 1 , D. Casey 2, W. Hoffman 2. 1 University Psychiatric Center Ibn Rushd, Casablanca, Morocco, USA, 2 Department of Psychiatry, VA Medical Center, Portland, Oregon, USA It has been assumed for the past 40 years that tardive dyskinesia (TO) Is due to neuroleptics only. A medico-legal consequence was that, in the United States, during the eighties, some patients suffering from TO received up to two million dollars compensation from courts. An Important question remains unanswered: does schizophrenia Itself represent a risk factor for these abnormal movements? In other words, do spontaneous abnormal movements exist In never medicated schizophrenic patients, and do they represent part of the clinical picture of this Illness? A few studies have been conducted in this field In the world, due to the high difficulty to find never medicated schizophrenic patients in centers with the expertise of research in this field, especially In industrialized countries. In Casablanca, a number of studies have been conducted, some of them In collaboration with the Department of Psychiatry of Portland, Oregon, USA. Some preliminary results of the last ongoing study are: Methods. and patients: 80 never medicated schizophrenics (G1), 61 treated schizophrenics (G2), and 52 normal controls (G3) were included, matched for sex, age and duration of Illness for the groups of schizophrenic patients. The mean age for the 3 groups was similar (G1: 29.36 ± 6 years; G2: 29.34 ± 5.52 years; G3: 32 ± 7.94 years). The mean duration of Illness was also similar in the two groups of patients (G1: 5.36 ± 3.89 years; 02: 5.72 ± 3.96 years). DSM IV criteria were used for the diagnosis, the SCIO and the SCID-NP for the clinical interview, the PANSS for the clinical assessment, and the Abnormal Involuntary Movement Scale (AIMS) for the assessment of the movements. Each examination of the abnomnal movements was videotaped with two cameras, and assessed in two ways: open and blind.