Primitive (developmental) reflexes and diffuse cerebral dysfunction in schizophrenia and bipolar affective disorder: overrepresentation in patients with tardive dyskinesia

From operational diagnostic to dimensional-continuum concepts of psychotic and non-psychotic illness: Embracing catatonia across psychopathology and intrinsic movement disorder in neural network dysfunction

Psychiatry is currently negotiating several challenges that are typified by (but are not unique to) schizophrenia: do periodic refinements in operational diagnostic algorithms (a) resolve intricacies and subtleties within and between psychotic and non-psychotic disorders that are authentic and impactful, or (b) constitute arbitrary and porous boundaries that should be complemented, or even replaced, by dimensional-continuum concepts of abnormality and dysfunction. Critically, these issues relate not only to apparent boundaries between diagnoses but also to those between 'health' and 'illness'. This article considers catatonia within evolving dimensional-continuum approaches to the description of impairment and dysfunction among psychotic and non-psychotic disorders. It begins by considering the definition and assessment of catatonia vis-à-vis other disorders, followed by its long-standing conjunction with schizophrenia, relationship with antipsychotic drug treatment, transdiagnostic perspectives and relationships, and pathobiological processes. These appear to involve dysfunction across elements in overlapping neural networks that result in a confluence of psychopathology and intrinsic hypo- and hyperkinetic motor dysfunction. It has been argued that while current diagnostic approaches can have utility in defining groups of cases that are closely related, contemporary evidence indicates categorical diagnoses to be arbitrary divisions of what is essentially a continuous landscape. Psychotic and non-psychotic diagnoses, including catatonia, may reflect arbitrary areas around points of intersection between orthogonal dimensions of psychopathology and intrinsic movement disorder in a poly-dimensional space that characterises this continuous landscape of mental health and dysfunction.

Structural alterations in brainstem, basal ganglia and thalamus associated with parkinsonism in schizophrenia spectrum disorders

The relative roles of brainstem, thalamus and striatum in parkinsonism in schizophrenia spectrum disorder (SSD) patients are largely unknown. To determine whether topographical alterations of the brainstem, thalamus and striatum contribute to parkinsonism in SSD patients, we conducted structural magnetic resonance imaging (MRI) of SSD patients with (SSD-P, n = 35) and without (SSD-nonP, n = 64) parkinsonism, as defined by a Simpson and Angus Scale (SAS) total score of ≥ 4 and < 4, respectively, in comparison with healthy controls (n = 20). FreeSurfer v6.0 was used for segmentation of four brainstem regions (medulla oblongata, pons, superior cerebellar peduncle and midbrain), caudate nucleus, putamen and thalamus. Patients with parkinsonism had significantly smaller medulla oblongata (p = 0.01, false discovery rate (FDR)-corrected) and putamen (p = 0.02, FDR-corrected) volumes when compared to patients without parkinsonism. Across the entire patient sample (n = 99), significant negative correlations were identified between (a) medulla oblongata volumes and both SAS total (p = 0.034) and glabella-salivation (p = 0.007) scores, and (b) thalamic volumes and both SAS total (p = 0.033) and glabella-salivation (p = 0.007) scores. These results indicate that brainstem and thalamic structures as well as basal ganglia-based motor circuits play a crucial role in the pathogenesis of parkinsonism in SSD.

Disinhibition of Primitive Reflexes in Attention Deficit and Hyperactivity Disorder: Insight Into Specific Mechanisms in Girls and Boys

Objective: Cognitive and motor disintegration and other functional disturbances in various neuropsychiatric disorders may be related to inhibitory deficits that may manifest as a persistence or re-expression of primitive reflexes and few recent data suggest that these deficits may occur in Attention Deficit and Hyperactivity Disorder (ADHD). Methods: We have tested a hypothesis to which extent ADHD symptoms and balance deficits are related to persisting primitive reflexes, such as Asymmetric Tonic Neck Reflex (ATNR) and Symmetric Tonic Neck Reflex (STNR) in 80 medication-naïve children with ADHD (40 boys and 40 girls) in the school age (8-11 years) and compared these data with a control group of 60 children (30 boys and 30 girls). Results: These data show new finding that ADHD symptoms and balance deficits are strongly and specifically associated with persistent ATNR in girls and STNR in boys. Conclusions: These results provide first evidence in medical literature that ADHD in girls and boys is specifically related to distinguished neurological developmental mechanisms related to disinhibition of primitive reflexes.

Principle of Dissolution and Primitive Reflexes in AD HD

According to current findings, in the history of neurology proposed by Hughlings Jackson, certain later developed functions during ontogenesis of the central nervous system (CNS) tend to replace the older ones. In this context, recent and historical findings suggest that certain later developed cognitive and motor functions during brain ontogenesis related to higher levels of coordination tend to replace the older ones and their persistence is linked to various neuropsychiatric disorders. Particularly important functional disturbances in ADHD developed early in life likely linked to dissolution process are balance deficits linked to dysfunctions of higher levels of coordination related to neurophysiological and mental functions that typically occur in ADHD. In this context, recent data suggest that one of the important aspects of normal development that may play a role in ADHD is suppression of the so-called primitive reflexes. Taken together these data suggest that ADHD symptoms may present a compensatory process related to interference of more primitive neural mechanism, as related to primitive reflexes, with higher levels of brain functions linked to coordination and balance due to insufficiently developed cognitive and motor integration.

Neurological soft signs in Chinese adolescents with schizophrenia and schizotypal personality traits

OBJECTIVE

Neurological soft signs (NSSs) may reflect neurodevelopmental anomalies in association with the spectrum of schizophrenia disorders. We examined NSSs in Chinese adolescents with schizophrenia and schizotypal personality traits.

METHODS

Eighty-seven schizophrenic adolescents (SCH group), 85 adolescents with only schizotypal personality traits (SPT group), and 88 healthy controls (HC group) were enrolled. The NSS subscales of the Cambridge Neurological Inventory (CNI) were administered to all 260 participants.

RESULTS

The NSS prevalence rates were higher in the SCH group than in the other two groups for both hands in the fist-edge-palm, Oseretsky, and graphesthesia tests. Relative to HCs, the SCH group also showed higher NSS prevalence rates in the right finger agnosia and right mirror movement of finger opposition tests. SCH>SPT>HC trends were observed for all NSS subscale scores and for the left, right, and total NSS scores.

CONCLUSIONS

To our knowledge, the present study is the first to examine NSSs in adolescents with schizophrenia and adolescents with schizotypal personality traits. These results provide preliminary findings suggesting that schizophrenia spectrum disorders may be characterized by developmental abnormalities in the central nervous system, and support the notion that NSSs may be schizophrenia spectrum disorder biomarkers.

Neurological soft signs predict abnormal cerebellar-thalamic tract development and negative symptoms in adolescents at high risk for psychosis: a longitudinal perspective

INTRODUCTION

There is an emerging consensus that neurological soft signs (NSS) may not be "soft" at all but rather may reflect neuropathy, particularly in the cerebellum and thalamus. However, our understanding of connective tract abnormalities is limited, and to date, there have been no investigations examining NSS and longitudinal white matter development during the prodrome. Mapping the correlates of NSS in ultrahigh-risk (UHR) youth offers potential for highlighting a viable biomarker as well as for advancing understanding of pathogenic processes during the adolescent risk period.

METHODS

A total of 68 (33 UHR and 35 healthy control) adolescents were assessed with an NSS inventory, structured interviews, and diffusion tensor imaging. Fractional anisotropy (FA) of theoretically relevant cerebellar-thalamic tracts was calculated (left/right superior cerebellar peduncles [SCPs]). Twelve months later, a subset of 30 (15 UHR and 15 control) participants returned for follow-up diffusion tension imaging/clinical assessments.

RESULTS

UHR youth exhibited elevated NSS across domains. While there were no group differences in the integrity of the SCPs at baseline, controls showed a normative increase while the UHR group showed a decrease in FA over 12 months. NSS predicted a longitudinal decrease in cerebellar-thalamic FA and elevations in negative but not positive symptoms 12 months later.

DISCUSSION

Findings of abnormal white matter development provide direct empirical evidence to support prominent neurodevelopmental theories. The predictive relationships between NSS and longitudinal cerebellar-thalamic tract integrity and negative symptom course provide insight into the role of cognitive dysmetria in the high-risk period and inform on a unique biomarker tied to core features underlying psychosis.

[Cortical Release Signs in Patients with Schizophrenia, Depressive Disorders, and Bipolar Affective Disorder]

BACKGROUND AND OBJECTIVES

Determining the presence of cortical release signs associated with white matter damage, is a clinically easy method to perform. The objective of this study is to determine the presence of cortical release signs in patients with mental illnesses and cerebrovascular disease, as well as its clinical usefulness, given that it indicates cortical damage.

MATERIAL AND METHODS

A review was made of cortical release signs in patients hospitalized in clinical psychiatry and general hospitals with bipolar affective disorder (40), depression (37), schizophrenia (33), cardiovascular disease (33) and dementia (37).

RESULTS

The signs of cortical release do not have the same importance as cortical damage. For example, the glabellar reflex was found in all the groups, that of paratonia, particularly in the group with schizophrenia, and others signs in the group of patients with dementia.

CONCLUSIONS

It is suggested that these signs imply subcortical white matter damage. The appearance of these signs shows the need for a follow up of patients diagnosed with bipolar affective disorder, depression and schizophrenia.

Persisting primitive reflexes in medication-naïve girls with attention-deficit and hyperactivity disorder

BACKGROUND AND OBJECTIVES

Recent and historical findings suggest that later-developed functions during brain ontogenesis related to higher levels of cognitive and motor integration tend to replace the older, more primitive, ones, and the persistence of the older functions may be linked to specific neuropsychiatric disorders. Currently, there is growing evidence to suggest that persisting primitive reflexes may be related to developmental and neurodegenerative disorders. Preliminary data also suggest that persisting primitive reflexes may be specifically linked to attention-deficit and hyperactivity disorder (ADHD).

METHODS

In the study reported here, we tested to what extent the persisting primitive asymmetric tonic neck reflex and symmetric tonic neck reflex are related to ADHD symptoms measured by Conners' Parent Questionnaire in 35 medication-naïve girls of school age (8-11 years) with ADHD. The results were compared with those of a control group of 30 girls of the same age.

RESULTS

This study showed that persisting primitive reflexes are closely linked to ADHD symptoms.

CONCLUSION

The data suggest that ADHD symptoms may be linked to more primitive neural mechanisms interfering with higher brain functions due to insufficiently developed cognitive and motor integration.

Clinical significance of neurological soft signs in schizophrenia: factor analysis of the Neurological Evaluation Scale

BACKGROUND

Nonlocalizing neurologic deficits detectable by clinical evaluation-"soft signs"-are a robust finding in patients diagnosed with schizophrenia, but their conceptual and neuroanatomical correlates remain unclear. The purpose of this study was to evaluate the organization of these deficits and their clinical correlates using the Neurological Evaluation Scale (NES).

METHODS

Ninety-three male veterans with schizophrenia and schizoaffective disorder were evaluated using a detailed clinical assessment that included the NES, the Extrapyramidal Symptom Rating Scale, the Abnormal Involuntary Movement Scale (AIMS), the Barnes Akathisia Scale, the Positive and Negative Syndrome Scale, the Wisconsin Card Sorting Test (WCST), the Schedule for the Deficit Syndrome (SDS), and the Digit Symbol Substitution Task (DSST).

RESULTS

Four factors explained 73% of the variance and had distinct clinical and neuropsychological correlates. Factor 1 reflected deficits involved with memory and sensory integration, and was associated with lower PANSS positive and higher AIMS scores. Factor 2 reflected impairments in motor control, and was associated with lower intelligence, more cognitive deficits, and deficit-syndrome schizophrenia. Factor 3 was related to lower intelligence and more perseverative errors on the WCST. Factor 4 was related to increasing age, more extrapyramidal symptoms, more perseverative errors, and worse scores on the DSST.

CONCLUSIONS

Neurologic deficits in schizophrenia have an intrinsic organization that appears to have clinical significance, highlighting the continued utility of the NES in studies of neurological deficits in schizophrenia patients. The theoretical underpinning of this organization remains unclear.

The relationship of pineal calcification and melatonin secretion to the pathophysiology of tardive dyskinesia and tourette's syndrome

Despite current intensive research, the pathophysiology of tardive dyskinesia (TD), a serious neurological side effect of neuroleptic treatment, is poorly understood. Prompted by the observation of an increased incidence and severity of abnormal perioral movements in neuroleptic-treated pinealectomized, as compared to intact rats, we suggested that the pineal gland exerts a protective effect which mitigates against the development of TD and, by inference, that reduced melatonin secretion may be related to the pathophysiology of TD. To investigate this proposition further, we studied the association of TD with pineal calcification (PC) on CT scan in chronic schizophrenic patients. Our findings revealed a significant association between TD and PC and suggest, furthermore, that PC may be a neuroradiological marker of TD. Since PC may reflect diminished secretory activity of the gland, these findings support the hypothesis that the pathophysiology of TD is linked to disturbances of melatonin secretion. The clinical and therapeutic implications of these novel findings are discussed. In the following communication, in which we introduce the hypothesis that disturbances of 5-HT and melatonin secretion are related to the pathophysiology of TD. Subsequently, we present a series of studies which relate to the association of TD with PC. We conclude by presenting the hypothesis that disturbances in melatonin secretion may also be relevant to the pathophysiology of Tourette's syndrome.

A neuropsychiatry service in a state hospital. Adolf Meyer's approach revisited

In the spirit of Adolf Mayer's medico-biological approach to the understanding of mental illnesses the article describes the advantages that neuropsychiatric approach brings to the diagnostic evaluation and treatment of psychiatric patients in a state hospital. Our review discusses the neuropsychiatric approach to the evaluation of state hospital patients with mild, moderate, and severe cognitive disturbances showing the role of neuropsychological testing, electroencephalography (EEG), and brain imaging in the neuropsychiatric assessment of primary and secondary mental illnesses. Neuropsychiatric evaluation helps to assess the peculiarities of movement disorder as a of side effects of regular psychiatric medications, e.g. the differences in diagnostic signs and treatment implication between Parkinson's disease and extrapyramidal syndrome (EPS) as a side effect of neuroleptics as well as the development of abnormal reflexes as a sign of tardive dyskinesia (TD) not directly related to the lesion of upper motor neuron. The article also discusses the development of hypokinetic delirium in the course of treatment of psychiatric patients not only as a side effect of neuroleptics but also of anticonvulsants, increasingly used as the mood stabilizers in modern psychiatry. Since aggressive behavior of psychiatric patients represents one of the major criteria for admission and often long term treatment in a state hospital, special consideration is given to the role of brain paroxysmal activity in the development of aggressive behavior, especially rage attacks, one of the main manifestations of aggressive behavior in a state hospital patients. Correspondingly, the use of anticonvulsants in the treatment of rage attacks is discussed. This article may serve as a model for the use of neuropsychiatric service in improvement of diagnostic evaluation and treatment of psychiatric patients in a state hospital.

Developmental reflexes and 31P Magnetic Resonance Spectroscopy of basal ganglia in antipsychotic-naive schizophrenia

The study examined the high energy-phosphate metabolism of basal ganglia in antipsychotic-naive schizophrenia patients with and without developmental reflexes in comparison to healthy subjects. Nineteen antipsychotic-naive schizophrenics of whom 11 had developmental reflexes and 26 age-sex-matched healthy subjects without developmental reflexes underwent in-vivo 2-D 31P Magnetic Resonance Spectroscopy of basal ganglia on a 1.5-T scanner. Mean age-at-onset of psychosis was significantly lower in patients with developmental reflexes. Mean PCr/Total ATP ratio in bilateral basal ganglia was lower in patients than healthy subjects. The ratio was the least in patients with developmental reflexes (F=10.7; df=2, 42; p<0.001). Schizophrenia patients with developmental reflexes had the lowest PCr/Total ATP ratio in basal ganglia indicating more severe metabolic abnormality. These patients had younger age-at-onset of psychosis. Together, this suggests neurodevelopmental etiopathogenesis in schizophrenia.

Motoric neurological soft signs and psychopathological symptoms in schizophrenic psychoses

Motoric neurological soft signs (NSS) were investigated by means of the Brief Motor Scale (BMS) in 82 inpatients with DSM-III-R schizophrenic psychoses. To address potential fluctuations of psychopathological symptoms and extrapyramidal side effects, patients were examined in the subacute state, twice at an interval of 14 days on the average. NSS were significantly correlated with severity of illness, lower social functioning, and negative symptoms. Modest, but significant correlations were found between NSS and extrapyramidal side effects as assessed on the Simpson-Angus Scale. Neither the neuroleptic dose prescribed to the patient, nor scores for tardive dyskinesia and akathisia were significantly correlated with NSS. Moreover, NSS scores did not significantly differ between patients receiving clozapine and conventional neuroleptics. Patients in whom psychopathological symptoms remained stable or improved over the clinical course showed a significant reduction of NSS scores. This finding did not apply to those patients in whom psychopathological symptoms deteriorated. Our findings demonstrate that NSS in schizophrenic psychoses are relatively independent of neuroleptic side effects, but they are associated with the severity and persistence of psychopathological symptoms and with poor social functioning.

The Brief Motor Scale (BMS) for the assessment of motor soft signs in schizophrenic psychoses and other psychiatric disorders

Subtle motor impairment is an important aspect of neurological soft signs (NSS) which are frequently found in psychiatric patients-particularly schizophrenic patients. On the basis of data collected in previous studies using two different NSS scales, the most reliable and discriminative signs of motor impairment were identified to construct a brief 10-item rating scale. Subsequently, the new scale was applied to a sample of subacute patients with schizophrenic psychoses (N = 82) and healthy controls (N = 33). Factor analysis identified two factors which were labeled "motor coordination" and "motor sequencing". Both the total score and the subscores showed high internal consistency and test-retest reliability. There were highly significant group differences on the total score and the subscores as well as on each individual task. The scale has high sensitivity (84.1%) and specificity (87.9%) indicating that it may provide an effective instrument for the screening of subjects with neurodysfunction as well as for monitoring motor dysfunction in the clinical course of psychiatric disorders.

Reduced cerebellar volume and neurological soft signs in first-episode schizophrenia

Recent studies indicate that morphological and functional abnormalities of the cerebellum are associated with schizophrenia. Since the cerebellum is crucial for motor coordination, one may ask whether the respective changes are associated with motor dysfunction in the disease. To test these hypotheses in a clinical study, we investigated cerebellar volumes derived from volumetric magnetic resonance imaging of 37 first-episode patients with schizophrenia, schizophreniform or schizoaffective disorder and 18 healthy controls matched for age, gender and handedness. To control for potential interindividual differences in head size, intracranial volume was entered as a covariate. Neurological soft signs (NSS) were examined after remission of acute symptoms. Compared with the controls, patients had significantly smaller cerebellar volumes for both hemispheres. Furthermore, NSS in patients were inversely correlated with tissue volume of the right cerebellar hemisphere partialling for intracranial volume. No associations were detected between cerebellar volumes and psychopathological measures obtained at hospital admission when patients were in the acute psychotic state or after remission, treatment duration until remission, treatment response or prognostic factors, respectively. These findings support the hypothesis of cerebellar involvement in schizophrenia and indicate that the respective changes are associated with NSS.

Cortical release signs in psychiatry

OBJECTIVE

To review the role of cortical release signs (CRS) in neuropsychiatry.

METHOD

A thorough literature review was conducted using Medline and Psychlit databases, and other relevant references available to the authors.

RESULTS

A number of neurological abnormalities are reported at elevated rates in neuropsychiatric conditions. CRS are a group of primitive reflexes that are present in the neonate but become inhibited as the infant central nervous system (CNS) develops, only to later re-emerge in the context of CNS disease. The clinical elicitation and interpretation of each CRS is described with reference to its neurobiology. The prevalence of CRS in schizophrenia, affective disorder, obsessive-compulsive disorder, Alzheimer's disease, vascular dementia, frontotemporal dementia and other neuropsychiatric illness allows for their use in the clinical management of these patients, including diagnostic assessment, treatment monitoring and prognosis.

CONCLUSIONS

A number of issues complicate their interpretation in neuropsychiatric illness, including the apparent high base rate of some CRS in non-clinical populations, their increasing prevalence with age, lack of specificity and uncertainty over what constitutes an 'abnormal' response. In some circumstances, CRS may assist in diagnostic differentiation and illness staging.

The palmomental reflex: a useful clinical sign?

The palmomental reflex, an involuntary contraction of the mentalis muscle of the chin caused by stimulation of the thenar eminence, can be tested easily and rapidly. Its presence may alert the clinician to the possibility of cerebral pathology. However, the reflex is often present in normal people and may be absent in disease states. Testing merely for the presence or absence of the reflex therefore lacks both specificity and sensitivity. A strong, sustained, and easily repeatable contraction of the mentalis muscle, which can be elicited by stimulation of areas other than the palm, is more likely to indicate cerebral damage.

How knowledge of regional brain dysfunction in depression will enable new somatic treatments in the next millennium

New knowledge about the specific brain regions involved in depression is rapidly evolving due to advances in functional neuroimaging techniques. Several new regionally specific somatic interventions build on this modern neuroanatomic information. These latest methods promise to revolutionize the understanding and treatment of depression. This article reviews the past and current use of these techniques, with an eye toward where they are heading in the next century.

Movement disorder in Down's syndrome: a possible marker of the severity of mental handicap

This study examined the nature and prevalence of abnormal movements in adults with Down's syndrome and also the clinical correlates of orofacial dyskinesia and the relationship between dyskinesia and the level of functional and intellectual disability. Movement disorder, language age, and disability were assessed in an epidemiologically based sample of 145 individuals with Down's syndrome. Abnormal involuntary movements were common, with > 90% exhibiting dyskinesia, predominantly orofacial. Stereotypes were present in one-third of the sample. There was an association between the severity of dyskinesia and both current language age and functioning in terms of self-care and practical and academic skills, which suggested that dyskinesia may be a marker of the severity of mental handicap. The presence of dyskinesia was unrelated to neuroleptic exposure. Dyskinesia and stereotypies are very common in individuals with Down's syndrome and may represent an inherent manifestation of the disorder. The relationship between mental age and dyskinesia in Down's syndrome warrants further research.

Tardive dyskinesia: a review

OBJECTIVE

To review recent research findings on tardive dyskinesia (TD) with relevance to clinical practice.

METHOD

TD is a syndrome of involuntary movements that can occur in association with chronic neuroleptic use. It is of unknown pathophysiology. It can be irreversible, is cosmetically disfiguring, and can be functionally disabling.

RESULTS

There is as yet no treatment of demonstrated efficacy for TD. It is an iatrogenic disorder whose incidence is increased by age and total cumulative dose of typical neuroleptics. It has been the source of successful litigation in some jurisdictions but, until very recently, there has been no effective antipsychotic agent without this effect.

CONCLUSION

This litigation in some jurisdictions has been a major impetus to the development of novel antipsychotic agents. It is less well known that a similar, possibly identical, movement disorder occurs spontaneously particularly in the elderly and in patients with schizophrenia, and that TD is often reversible.

Neuroleptic associated tardive dyskinesias in young people with psychoses

BACKGROUND

Apart from ageing, the factors associated with vulnerability to the emergence of tardive dyskinesia are poorly defined.

METHOD

Risk factors associated with the presence of a chronic choreic or dystonic disorder were assessed in a cross-sectional comparison of anamnestic and clinical data in a homogeneous group of 64 young psychotic patients (under 40 years of age) on chronic low to moderate doses of neuroleptics.

RESULTS

Dyskinetic subjects presented more indirect indicators of occult brain damage, such as a perinatal event or traumatic brain injuries in infancy and early childhood; neurological examination showed more anomalies in dyskinetic patients than in nondyskinetics, with a higher prevalence of facial release reflexes.

CONCLUSION

These data may support the hypothesis that occult acquired brain damage is important in the genesis of this 'drug-induced' disorder.

Schizophrenics with small P300: a subgroup with a neurodevelopmental disturbance and a high risk for tardive dyskinesia?

Schizophrenics with a neurodevelopmental disturbance resulting in micro- and macroanatomical cortical abnormalities are supposed to form a subgroup clinically characterized by low premorbid adjustment, early onset, incomplete remission, poor outcome, male predominance and high risk for tardive dyskinesia. A small amplitude of the event-related P3 (P300) potential could be a marker of this subgroup, because the cortical neurons and their orderly laminar arrangement are crucial for the electrogenesis of P3. In a 2-year follow-up study, auditory evoked P3 was recorded in 89 stabilized schizophrenic outpatients. Patients who developed tardive dyskinesia during the follow-up had smaller P3 than matched controls. Furthermore, a small P3 was associated with low premorbid adjustment, pronounced residual symptoms, low relapse rate, and male predominance. These findings indicate that schizophrenic patients with a reduced P3 have a higher risk of developing tardive dyskinesia and correspond clinically to a schizophrenic subgroup with a supposedly neurodevelopmental disturbance.

Blinking and the release reflexes: are they clinically useful?

OBJECTIVE

To review the clinical utility of blinking and the release reflexes, palmomental, glabellar, grasp, and snout, as an important part of the bedside neurological examination.

DESIGN

Articles published from 1966 to 1993 that addressed blinking or the release reflexes were identified by searching the MEDLINE database. Thirty-seven references provided clinically useful and applicable information.

RESULTS

There is controversy regarding the optimal method of clinical elicitation of these reflexes. The release reflexes are frequently seen as an incidental abnormality in the elderly. A positive grasp reflex, especially if asymmetrical, is sensitive but not specific for abnormal brain function. Lack of habituation is more important than the mere presence or absence of a reflex. The brainstem circuits involved in the regulation of blinking and the release reflexes are discussed, as are their abnormalities in a variety of clinical settings.

CONCLUSION

Blinking and the release reflexes have clinical utility in the diagnosis and bedside clinical assessment of diseases as diverse as frontal lobe lesions, hydrocephalus, multiple sclerosis, Parkinson's disease, Alzheimer's disease and other dementias, falls in the elderly, ageing, HIV-encephalopathy, schizophrenia, tumors in the region of the sylvian aqueduct and recovery from head trauma.

Tardive dyskinesia and type II schizophrenia

Cognitive impairment, negative and positive symptoms, primitive release reflexes, and age/temporal disorientation were assessed in 20 male patients meeting the DSM-III-R criteria for chronic schizophrenia and Schooler & Kane's criteria for TD. The control group comprised 20 age-matched male chronic schizophrenic patients without TD. Significant associations were found between TD, cognitive impairment, some negative symptoms, and formal thought disorder. These associations were independent of other illness and treatment variables. The severity of TD correlated significantly with that of cognitive impairment.

Risk factors for neuroleptic-induced movement disorders

Chronic neuroleptic therapy may be associated with the development of diverse movement disorders including Tardive dyskinesia (TD), Parkinsonism, dystonia, and akathisia in a subset of schizophrenic patients. It is presently unknown why only a proportion of neuroleptic-treated patients develop these movement disorders. In the following communication, we present a series of studies which demonstrate that the development of these movement disorders may be facilitated by certain risk factors including disturbances in pineal melatonin functions, diabetes mellitus, cognitive deficits, suicidal behavior, and disturbances in the functions of the choroid plexus. Recognition of these biological factors may prove useful in: (a) further understanding of the pathophysiology of these disorders, and (b) identifying patients at risk for these movement disorders.

The clinical correlates of neurological soft signs in chronic schizophrenia

Among 16 chronic schizophrenic in-patients, all had at least one neurological soft sign (NSS), and 6 (40%) had definite neurodysfunction. NSS and TD scores were highly intercorrelated, and NSS were significantly correlated with neuroleptic drug exposure. NSS correlated positively with both positive and negative symptoms and cognitive impairment but not with cerebral ventricular size on CT. Patients with neurodysfunction had more positive and negative psychopathology, cognitive impairment and TD than those without. Cerebral ventricular sizes and family histories of schizophrenia were similar in both NSS groups. The presence of NSS may be a simple but important way of identifying a subgroup of schizophrenics with neurodevelopmental predisposing abnormalities, and vulnerability to TD.

Neuroradiological covariates of drug-induced parkinsonism and tardive dyskinesia in schizophrenia

Computed tomographic (CT) studies have demonstrated structural brain abnormalities including cortical atrophy and enlarged lateral ventricles in a subset of schizophrenic patients including those with abnormal involuntary movements. In the following series of studies, we present our findings pertaining to neuroradiological covariates of drug-induced Parkinsonism and Tardive dyskinesia in schizophrenic patients. In these studies we have explored the relationship of Parkinsonism and Tardive dyskinesia to pineal and choroid plexus calcification. In addition, we also investigated the relationship of pineal calcification to schizophrenia, and specifically to the paranoid and nonparanoid subgroups. In a further series of studies, we investigated the neuroradiological covariates of disorders of gait and posture as well as tremor in schizophrenic patients with drug-induced Parkinsonism. In addition, we explored the relationship of Tardive dyskinesia and its subsyndromes to CT scan measurements of cortical and subcortical atrophy in schizophrenia. Our findings highlight the significance of the pineal gland in the pathophysiology of schizophrenia and drug-induced movement disorders. Furthermore, these studies underscore the heterogeneity of Parkinsonism and Tardive dyskinesia.

The relationship of tardive dyskinesia to positive schizophrenia

Investigations aimed at identifying the clinical characteristics that discriminate Tardive dyskinesia (TD) from non-TD patients have yielded disparate findings. A number of studies have suggested that TD may be a feature of negative schizophrenia. In particular, the association of TD with high prevalence of "soft" neurological signs, cognitive deficits, and abnormal brain morphology on CT scan in some patients, have led several investigators to propose that negative schizophrenia may be a risk factor for TD. The neurochemical profile of TD, however, is not consistent with this hypothesis. In the following communication, we present our studies which suggest that TD is specific to and an intergral part of positive schizophrenia. The data suggest that schizophrenic patients with predominant positive symptoms may be at increased risk for the development of TD. In addition, we present evidence linking TD with left cerebral hemispheric dysfunction. By comparison, we provide evidence that negative schizophrenia is related to diencephalic damage, and discuss its relevance to negative schizophrenia and to Parkinsonism. We also provide evidence that negative schizophrenia may be a risk factor for acute drug-induced dystonia. Thus, these findings are consistent with our model that negative schizophrenia is a risk factor for Parkinsonism, whereas positive schizophrenia is related to TD. In analogy with the positive/negative dichotomy of schizophrenia, we propose that TD could be considered a "positive," where Parkinsonism a "negative" movement disorder.

Obstetric complications, the putative familial-sporadic distinction, and tardive dyskinesia in schizophrenia

Obstetric complications were more common in the histories of those schizophrenic outpatients without a family history of psychiatric disorder, and were associated with an earlier onset of their illness. Those patients with tardive dyskinesia were more likely to have a family history of psychiatric disorder, less likely to have experienced obstetric complications, and showed greater cognitive deficit. Obstetric complications should be considered in juxtaposition with genetic factors in evaluating the putative familial-sporadic distinction in schizophrenia. Additionally, familial/genetic factors appears to contribute to vulnerability to tardive dyskinesia.

Serum immunoglobulins in tardive dyskinesia — implication for pathogenesis of the syndrome

Levels of immunoglobulins were measured in 32 schizophrenic patients with tardive dyskinesia and 34 schizophrenic patients without tardive dyskinesia. The duration of neuroleptic treatment in years was similar in the two groups. The serum immunoglobulin concentrations (mg%) were found to be significantly different in the two groups; IGA and IGM levels were higher in patients with tardive dyskinesia. The present results may be explained on the basis of dysfunction of the immunological system in tardive dyskinesia.

Possible role of pineal melatonin in the mechanisms of aging

The pineal gland has captured man's attention as early in recorded history as the Greeks when philosophers considered it the "seat of the soul". Descartes, in the Middle Ages, furthered this concept naming it "esprits animaux" or, in current language, the psychic and somatic activating principle. These notions about the pineal gland were initially purely speculative and unsupported by scientific facts. However, with the development of a sound knowledge base concerning the pineal gland over the past twenty years, evidence has accumulated to suggest a pivotal role for the pineal in the 'fine tuning' and integrating of various neural and endocrine functions. The secretion of pineal melatonin has been shown to decline progressively with age. Recent hypotheses of aging have suggested that cumulative neuronal insults associated with free radical production may be associated with the process of aging. There is evidence to suggest that melatonin may protect against the age processes in part by attenuating the effects of free radical-induced neuronal damage. Other studies derived mainly from observations on pinealectomized rats also suggest that diminished melatonin secretion may be associated with acceleration of the aging process. Thus, pineal melatonin may be a natural anti-aging hormone.

Melanocyte-stimulating hormone and persistent tardive dyskinesia: a hypothesis

An increased incidence of abnormal perioral movements has recently been reported in drug-naive pinealectomized rats with further accentuation of these movements following administration of haloperidol. Analysis of the temporal course of the development of the perioral dyskinetic movements revealed that the onset of these movements occurred within 4 days postoperatively and peaked at 3 weeks to plateau over the following 4-6 weeks. Increased pituitary Melanocyte-stimulating hormone (MSH) content has been reported in pinealectomized rats. Elevation of MSH content in the pinealectomized rats occurred within 3 days of surgery and was followed by normalization within 4 weeks. These findings suggest that compensatory mechanisms involving hypothalamic-pituitary MSH release must have been activated to induce normalization of pituitary MSH levels. Moreover, reduction of pituitary MSH levels may have coincided with attenuation in the severity of the perioral dyskinetic movements. It is possible that the development of tardive dyskinesia (TD) may in part be associated with increased brain and plasma MSH levels and that impaired hypothalamic-pituitary regulatory mechanisms of MSH release may be associated with persistent TD. The pineal gland may be implicated in this process as diminished melatonin secretion may be associated with disinhibition of MSH release. Thus, the above hypothesis complements and extends the recently presented "melatonin hypothesis" and suggests that research of pineal-hypothalamic interactions may be crucial to the further understanding of TD.

Cognitive impairment, clinical course and treatment history in out-patients with bipolar affective disorder: relationship to tardive dyskinesia

Clinical, neuropsychological and psychopharmacological characteristics were investigated for their ability to distinguish individuals with and without involuntary movements (tardive dyskinesia), among a population of 40 out-patients with bipolar affective disorder and a history of exposure to neuroleptics and lithium. Impaired performance on a test of cognitive flexibility bore the primary association with both the presence and the severity of involuntary movements. The additional relationships identified emphasized further that individual vulnerability to involuntary movements appeared to be associated not with greater duration or dosage of treatment, but with features of the bipolar illness, including number and type of affective episodes, for which that treatment was prescribed.

Can the supersensitivity of rodents to dopamine be regarded as a model of tardive dyskinesia?

1. The paper presents arguments derived from both, clinical work and animal experiments, for or against the traditional hypothesis suggesting that tardive dyskinesia (TD) is caused by supersensitivity to dopamine. The main aim of this study was to answer the question posed in the title - whether the supersensitivity to dopamine evoked in rodents by neuroleptics can be regarded as an adequate pharmacological model of TD. 2. The data presented here prove that chronic administration of neuroleptics to schizophrenic patients cannot be the only factor inducing TD; furthermore, symptoms similar or identical to those of TD are also observed in the course of other disorders, not connected with neuroleptics, e.g. aging or schizophrenia itself. 3. Clinical data offer no clear evidence for the existence of a direct cause-effect relationship between super-sensitivity to dopamine and occurrence of TD. 4. The role of brain degeneration, caused by different factors but in particular by the process of aging, in the pathogenesis of dyskinetic disorders, including TD, has been stressed. 5. Pharmacological and biochemical data show that chronic administration of classic neuroleptics to animals induces an increase in the density of dopamine D-2 receptors (Bmax). It seems that this receptor-mediated supersensitivity may concern both the postsynaptic and the presynaptic D-2 dopamine receptors. On the other hand, it is not clear enough whether a dopamine D-1 receptor-mediated supersensitivity might also be a causal factor of TD. 6. The analysis in animals, of biochemical and pharmacological effects of neuroleptics which do not induce TD showed that in some situations these drugs may also evoke the receptor-mediated supersensitivity concerning dopamine D-2 receptors. 7. The method of a prolonged (approx. 1 year) oral administration of neuroleptics seems to differentiate those which induce TD from those which do not, at least regarding the induction of an increase of Bmax for butyrophenone neuroleptics and an increase of apomorphine-induced stereotypy, however, some exceptions are noted. 8. The above analysis of clinical and experimental data suggests that the supersensitivity to dopamine in rats treated chronically with neuroleptics cannot be accepted as a model which reflects the etiopathogenesis of TD. Neither a positive nor a negative result obtained in this test is reliable enough, and either depends on the tested parameters (apomorphine stereotypy and [3H]spiperon binding seem to be the most reliable), route of neuroleptic administration, duration of treatment and, probably, a number of other, still unknown factors.(ABSTRACT TRUNCATED AT 400 WORDS)

Calcium metabolism and abnormal involuntary movements (tardive dyskinesia) in psychosis

Serum calcium levels were measured in 25 chronically ill psychotic inpatients with involuntary movements, in comparison with 25 otherwise indistinguishable patients without such a syndrome. Those with involuntary movements were significantly more likely to have a serum calcium level below the normal range. These results are discussed in terms of the role of calcium in neuronal dysfunction, and in broader aspects of the general biological disadvantage that appears to characterize older patients with this movement disorder.

Involuntary orofacial movements in hospitalised patients with mental handicap or epilepsy: relationship to developmental/intellectual deficit and presence or absence of long-term exposure to neuroleptics

Among 42 adult patients with mental handicap who had received treatment with neuroleptic drugs, the prevalence of orofacial dyskinesia increased with age and those with such involuntary movements were characterised by a considerably greater degree of mental handicap. Similar associations were found among a group of 15 patients with epilepsy. Two of seven other mentally handicapped patients and one of eight other epileptic patients showed indistinguishable orofacial dyskinesia, despite no record of them having received neuroleptic drugs.