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Neurological soft signs in chronic schizophrenic patients: Clinical correlates
458
BIOL PSYCHIATRY 1988;24:45&460
Neurological Soft Signs in Chronic Schizophrenic Patients: Clinical Correlates Gyijrgy Bartk6, Gyargy Zidor, Szabolcs HorvSlth, and Ilona Herczeg
Introduction Several studies have demonstrated the high prevalence of certain neurological abnormalities of doubtful localizing value, so-called soft signs, in schizophrenic patients (Quitkin et al. 1976, Rochford et al. 1970, Tucker et al. 1975; Nasrallah et al. 1982). The clinical, especially the psychopathological, implications of these neurological impairments have been only partially elucidated. Tucker et al. (1975) found a strong correlation between neurological abnormalities and formal thought disorder, particularly, but not exclusively, among schizophrenic subjects. This was continned by Mans&reck et al. (1981), who also found that this association was especially valid with regard to motor disturbances. Only a few studies have examined the correlation between negative symptoms and soft signs, although it has been suggested that certain negative symptoms may have some underlying structural background. Kolakowska et al. (1985) could not find any relationship between negative or positive symptoms and soft signs. In agreement with Nasrallah et al. (1983), who claimed that neurological soft signs were as common in manic as in schizophrenic patients, they concluded that they may well be nonspecific features of various psychoses, without specific clin-
From the National Institute for Nervous and Mental Diseases, Budapest, Hungary. Address reprint requests to Dr. Gy. Bartkb, National Institute for Nervous and Mental Diseases, 1281 Budapest, Pf.1.. Hungary. Received September 26, 1987; revised November 16. 1987.
0 1988 Society of Biological
Psychiatry
ical significance. Studies of the association of soft signs with other dysfunctions, such as cognitive impairment, have been inconclusive. Some authors have claimed a relationship between severity of intellectual deficit and the presence of minor neurological abnormalities (Quitkin et al. 1976; Kolakowska et al. 1985). According to Mans&reck and Ames (1984), this relationship was also influenced by the overall severity of the illness. Other clinical factors, such as sex, age, length of illness, and drug status, and nonspecific factors, such as attention and cooperation, may also have some relationship to these neurological deficits (Mans&reck and Ames 1984). The aim of our investigation was to determine the prevalence of neurological soft signs in our chronic schizophrenic patients and to determine their relation to positive and negative symptoms, to the overall severity of the psychopathological features, and to cognitive disturbances .
Methods Fifty-eight schizophrenic patients (30 women and 28 men) were selected from the two psychiatric departments of our institute. The diagnoses were established on the basis of the Research Diagnostic Criteria (RDC) (Spitzer et al. 1975). Twenty-eight patients were paranoid, 5 were catatonic, 13 were undifferentiated, and 12 were disorganized schizophrenics; all were chronic cases. Only patients between 18 and 55
OtXK-3223/88/$03.50
BIOL PSYCHIATRY 1988;24:458-%0
Brief Reports
Table 1. Relationshipamong Positive and Negative Symptoms, Overall Severity of Psychiatric Disturbance, Cognitive Status, and Neurological Soft Signs in Schizophrenic Patients (n = 58) r* Positive symptoms (BPRS) Conceptualdisorganization Hallucinatorybehavior Excitement Gradiosity Suspiciousness Hostility Negative symptoms (SANS) Affective flattening Alogia Avolition-+pathy Anhedonia-asociality Attentional impairment Overall severity of psychiatric disturbance(GAS) Cognitive status (MMS)
P
0.23 0.15 0.08 0.17 0.10 0.05
NS NS NS NS NS NS
0.09 0.29 0.10 0.15 0.18
NS NS” NS NS NS
-0.29 -0.22
%onferroni correction reduces significance criteriontop
NS” NS <0.0038.
years, of average intelligence, and free of severe somatic, neurological, or secondary psychiatric disorders were included in the study. The mean age of the patients was 43.1 ? 8.6 years, the mean duration of illness was 12.5 + 8.5 years, the mean number of hospitalizations was 8.5 ? 5.1, and the mean length of education 10.1 2 2.3 years. The patients were in a stable state during the study and were receiving maintenance neuroleptic medication at a mean dose of 365 ? 25 1 mg/day, expressed in chlorpromazine equivalent (Davis 1976). Eighteen patients exhibited mild extrapyramidal features, whereas 10 patients showed evidence of tardive dyskinesia, all at minimal levels of severity. The positive symptoms were assessed on the items hallucinatory behavior, conceptual disorganization, excitement, grandiosity, suspiciousness, and hostility on the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham 1962). The negative symptoms were rated on the Scale for Assessment of Negative Symptoms (SANS) (Andmasen 1981). The overall severity of psychiatric disturbance was assessed on the Global Assessment Scale (GAS) (Endicott et al. 1976);
459
the Mini Mental State (MMS) (Folstein et al. 1975) was used to assess cognitive functions. The following neurological soft signs were rated for each patient on a l-3 scale (absent, present, marked) by a physician who was blind to the goal of the study: right/left confusion, finger to thumb opposition, mirror movements, pronation and supination, stereognosis, graphesthesia, extinction, grasp reflex, and palmomental reflex. Each sign, with the exception of the first, was evaluated on both sides. Student’s r-test and the Spearman rank correlation were used to evaluate the data.
Results Of the 58 schizophrenic subjects, 7 did not have any soft signs, 13 had one, 12 had two, and 26 patients had 3 or more. The most frequently encountered soft signs were mirror movements (35 patients), graphesthesia (23 patients), and palmomental reflex (22 patients). There was no relationship between sex (r = 0.85, NS), age (rs = 0.18, NS), length of illness (r, = 0.05 Ns), the actual neuroleptic dose ( rs = 0.21, NS), score on the “attention” subscale of MMS (r, = 0.19, NS), and the total score for soft signs. There was no significant correlation among the scores of the positive symptoms on the BPRS, the scores of the negative symptoms on the SANS, the GAS score, MMS score, and the total score for soft signs (Table 1).
Discussion Our results confirm the high prevalence of neurological soft signs in schizophrenic patients. We observed at least two minor neurological abnormalities in 60% and at least three soft signs in 45 % of our schizophrenic subjects. This ratio is somewhat lower than the data reported by others (Rochford et al. 1970; Tucker et al. 1975; Kolakowska et al. 1985), but this may well be due to methodological differences. The neurological soft signs were unrelated to sex, age, duration of illness, drug status, or
460
BIOL PSYCHIATRY 1988;24:458-%0
attentional deficit. The absence of any significant association among positive and negative symptomatology, overall severity of psychiatric disturbance, cognitive status, and soft signs suggests that minor neurological abnormalities may be a nonspecific indicator of organic brain dysfunction, of no particular clinical significance. This interpretation is in accord with the conclusions of other studies (Nasrallah et al. 1982, 1983; Kolakowska et al. 1985).
Brief Reports
rological “soft” signs, cognitive impairment and their clinical significance. Er / Psychiurry 146~348-357. Nasrallab HA, Tippin J, McCalley-Whitters M, Kuperman S (1982): Neurological differences between paranoid and nonparanoid schizophrenia: Part III. Neurological soft signs. J Clin Psychiatry 42:3 10-3 12. Nasrallah HA, Tippin J, McCalley-Whittets M (1983): Neurological soft signs in manic patients: A comparison with schizophrenics and control groups. J Aflect Dis 5:45SO. Mans&reck TC, Ames D (1984): Neurologic features and psychopathology in schizophrenic disorders. Biol Psychiatry 5:703-719.
References
Mans&reck TC, Maher BA, Ader DN (1981): Formal thought disorder, the type-token ratio, and disturbed voluntary motor movement in schizophrenia. Br J Psychiatry 139:715.
Andreasen NC (198 1): Scale for rhe Assessmenf of Negative Symproms. Iowa City: University of Iowa.
Overall JE, Gorham DR (1962): The Brief Psychiatric ing Scale. Psycho1 Rep 10:799-812.
Davis JM (1976): Comparative doses and costs. of antipsychotic medication. Arch Gen Psychiurry 33:858-861.
Quitkin F, R&in A, Klein D (1976): Neurologic soft signs in schizophrenia and character disorders. Arch Gen Psychiatry 33:845-853.
Endicott J, Spitzer RL, Fleiss J, Cohen J (1976): The Global Assessment Scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 33:766-711.
Rochford J, Detre T, Tucker G, Harrow J (1970): Neuropsychological impairments in functional psychiatric discases. Arch Gen Psychiatry 22:114-l 19.
Folstein MF, Folstein SE, McHuagh (1975): “Mini Mental State” A practical method for grading the cognitive state of patients for clinician. J Psychian Res 12: 189-198. Kolakowska T, Williams AO, Jambor K, Ardem N (1985): Schizophrenia with good and poor outcome. III. Neu-
Rat-
Spitzer RL, Endicott J, Robins E (1975): Research Diagnostic Criteria (ed 2). New York: New York State Psychiatric Institute. Tucker GJ, Campion EW, Silberfarb PM (1975): Sensorimotor functions and cognitive disturbance in psychiatric patients. Am J Psychiatry 132:17-21.
BIOL PSYCHIATRY 1988;24:45&460
Neurological Soft Signs in Chronic Schizophrenic Patients: Clinical Correlates Gyijrgy Bartk6, Gyargy Zidor, Szabolcs HorvSlth, and Ilona Herczeg
Introduction Several studies have demonstrated the high prevalence of certain neurological abnormalities of doubtful localizing value, so-called soft signs, in schizophrenic patients (Quitkin et al. 1976, Rochford et al. 1970, Tucker et al. 1975; Nasrallah et al. 1982). The clinical, especially the psychopathological, implications of these neurological impairments have been only partially elucidated. Tucker et al. (1975) found a strong correlation between neurological abnormalities and formal thought disorder, particularly, but not exclusively, among schizophrenic subjects. This was continned by Mans&reck et al. (1981), who also found that this association was especially valid with regard to motor disturbances. Only a few studies have examined the correlation between negative symptoms and soft signs, although it has been suggested that certain negative symptoms may have some underlying structural background. Kolakowska et al. (1985) could not find any relationship between negative or positive symptoms and soft signs. In agreement with Nasrallah et al. (1983), who claimed that neurological soft signs were as common in manic as in schizophrenic patients, they concluded that they may well be nonspecific features of various psychoses, without specific clin-
From the National Institute for Nervous and Mental Diseases, Budapest, Hungary. Address reprint requests to Dr. Gy. Bartkb, National Institute for Nervous and Mental Diseases, 1281 Budapest, Pf.1.. Hungary. Received September 26, 1987; revised November 16. 1987.
0 1988 Society of Biological
Psychiatry
ical significance. Studies of the association of soft signs with other dysfunctions, such as cognitive impairment, have been inconclusive. Some authors have claimed a relationship between severity of intellectual deficit and the presence of minor neurological abnormalities (Quitkin et al. 1976; Kolakowska et al. 1985). According to Mans&reck and Ames (1984), this relationship was also influenced by the overall severity of the illness. Other clinical factors, such as sex, age, length of illness, and drug status, and nonspecific factors, such as attention and cooperation, may also have some relationship to these neurological deficits (Mans&reck and Ames 1984). The aim of our investigation was to determine the prevalence of neurological soft signs in our chronic schizophrenic patients and to determine their relation to positive and negative symptoms, to the overall severity of the psychopathological features, and to cognitive disturbances .
Methods Fifty-eight schizophrenic patients (30 women and 28 men) were selected from the two psychiatric departments of our institute. The diagnoses were established on the basis of the Research Diagnostic Criteria (RDC) (Spitzer et al. 1975). Twenty-eight patients were paranoid, 5 were catatonic, 13 were undifferentiated, and 12 were disorganized schizophrenics; all were chronic cases. Only patients between 18 and 55
OtXK-3223/88/$03.50
BIOL PSYCHIATRY 1988;24:458-%0
Brief Reports
Table 1. Relationshipamong Positive and Negative Symptoms, Overall Severity of Psychiatric Disturbance, Cognitive Status, and Neurological Soft Signs in Schizophrenic Patients (n = 58) r* Positive symptoms (BPRS) Conceptualdisorganization Hallucinatorybehavior Excitement Gradiosity Suspiciousness Hostility Negative symptoms (SANS) Affective flattening Alogia Avolition-+pathy Anhedonia-asociality Attentional impairment Overall severity of psychiatric disturbance(GAS) Cognitive status (MMS)
P
0.23 0.15 0.08 0.17 0.10 0.05
NS NS NS NS NS NS
0.09 0.29 0.10 0.15 0.18
NS NS” NS NS NS
-0.29 -0.22
%onferroni correction reduces significance criteriontop
NS” NS <0.0038.
years, of average intelligence, and free of severe somatic, neurological, or secondary psychiatric disorders were included in the study. The mean age of the patients was 43.1 ? 8.6 years, the mean duration of illness was 12.5 + 8.5 years, the mean number of hospitalizations was 8.5 ? 5.1, and the mean length of education 10.1 2 2.3 years. The patients were in a stable state during the study and were receiving maintenance neuroleptic medication at a mean dose of 365 ? 25 1 mg/day, expressed in chlorpromazine equivalent (Davis 1976). Eighteen patients exhibited mild extrapyramidal features, whereas 10 patients showed evidence of tardive dyskinesia, all at minimal levels of severity. The positive symptoms were assessed on the items hallucinatory behavior, conceptual disorganization, excitement, grandiosity, suspiciousness, and hostility on the Brief Psychiatric Rating Scale (BPRS) (Overall and Gorham 1962). The negative symptoms were rated on the Scale for Assessment of Negative Symptoms (SANS) (Andmasen 1981). The overall severity of psychiatric disturbance was assessed on the Global Assessment Scale (GAS) (Endicott et al. 1976);
459
the Mini Mental State (MMS) (Folstein et al. 1975) was used to assess cognitive functions. The following neurological soft signs were rated for each patient on a l-3 scale (absent, present, marked) by a physician who was blind to the goal of the study: right/left confusion, finger to thumb opposition, mirror movements, pronation and supination, stereognosis, graphesthesia, extinction, grasp reflex, and palmomental reflex. Each sign, with the exception of the first, was evaluated on both sides. Student’s r-test and the Spearman rank correlation were used to evaluate the data.
Results Of the 58 schizophrenic subjects, 7 did not have any soft signs, 13 had one, 12 had two, and 26 patients had 3 or more. The most frequently encountered soft signs were mirror movements (35 patients), graphesthesia (23 patients), and palmomental reflex (22 patients). There was no relationship between sex (r = 0.85, NS), age (rs = 0.18, NS), length of illness (r, = 0.05 Ns), the actual neuroleptic dose ( rs = 0.21, NS), score on the “attention” subscale of MMS (r, = 0.19, NS), and the total score for soft signs. There was no significant correlation among the scores of the positive symptoms on the BPRS, the scores of the negative symptoms on the SANS, the GAS score, MMS score, and the total score for soft signs (Table 1).
Discussion Our results confirm the high prevalence of neurological soft signs in schizophrenic patients. We observed at least two minor neurological abnormalities in 60% and at least three soft signs in 45 % of our schizophrenic subjects. This ratio is somewhat lower than the data reported by others (Rochford et al. 1970; Tucker et al. 1975; Kolakowska et al. 1985), but this may well be due to methodological differences. The neurological soft signs were unrelated to sex, age, duration of illness, drug status, or
460
BIOL PSYCHIATRY 1988;24:458-%0
attentional deficit. The absence of any significant association among positive and negative symptomatology, overall severity of psychiatric disturbance, cognitive status, and soft signs suggests that minor neurological abnormalities may be a nonspecific indicator of organic brain dysfunction, of no particular clinical significance. This interpretation is in accord with the conclusions of other studies (Nasrallah et al. 1982, 1983; Kolakowska et al. 1985).
Brief Reports
rological “soft” signs, cognitive impairment and their clinical significance. Er / Psychiurry 146~348-357. Nasrallab HA, Tippin J, McCalley-Whitters M, Kuperman S (1982): Neurological differences between paranoid and nonparanoid schizophrenia: Part III. Neurological soft signs. J Clin Psychiatry 42:3 10-3 12. Nasrallah HA, Tippin J, McCalley-Whittets M (1983): Neurological soft signs in manic patients: A comparison with schizophrenics and control groups. J Aflect Dis 5:45SO. Mans&reck TC, Ames D (1984): Neurologic features and psychopathology in schizophrenic disorders. Biol Psychiatry 5:703-719.
References
Mans&reck TC, Maher BA, Ader DN (1981): Formal thought disorder, the type-token ratio, and disturbed voluntary motor movement in schizophrenia. Br J Psychiatry 139:715.
Andreasen NC (198 1): Scale for rhe Assessmenf of Negative Symproms. Iowa City: University of Iowa.
Overall JE, Gorham DR (1962): The Brief Psychiatric ing Scale. Psycho1 Rep 10:799-812.
Davis JM (1976): Comparative doses and costs. of antipsychotic medication. Arch Gen Psychiurry 33:858-861.
Quitkin F, R&in A, Klein D (1976): Neurologic soft signs in schizophrenia and character disorders. Arch Gen Psychiatry 33:845-853.
Endicott J, Spitzer RL, Fleiss J, Cohen J (1976): The Global Assessment Scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 33:766-711.
Rochford J, Detre T, Tucker G, Harrow J (1970): Neuropsychological impairments in functional psychiatric discases. Arch Gen Psychiatry 22:114-l 19.
Folstein MF, Folstein SE, McHuagh (1975): “Mini Mental State” A practical method for grading the cognitive state of patients for clinician. J Psychian Res 12: 189-198. Kolakowska T, Williams AO, Jambor K, Ardem N (1985): Schizophrenia with good and poor outcome. III. Neu-
Rat-
Spitzer RL, Endicott J, Robins E (1975): Research Diagnostic Criteria (ed 2). New York: New York State Psychiatric Institute. Tucker GJ, Campion EW, Silberfarb PM (1975): Sensorimotor functions and cognitive disturbance in psychiatric patients. Am J Psychiatry 132:17-21.