Neurological soft signs in obsessive-compulsive disorder: the effect of co-morbid psychosis and evidence for familiality

Prevalence of Neurological Soft Signs at Presentation in Pediatric Acute-Onset Neuropsychiatric Syndrome

Importance

Studies of brain imaging and movements during REM sleep indicate basal ganglia involvement in pediatric acute-onset neuropsychiatric syndrome (PANS). Characterizing neurological findings commonly present in patients with PANS could improve diagnostic accuracy.

Objective

To determine the prevalence of neurological soft signs which may reflect basal ganglia dysfunction (NSS-BG) in youth presenting with PANS and whether clinical characteristics of PANS correlate with NSS-BG. Design, Setting, and Participants: 135 new patients who were evaluated at the Stanford Children's Immune Behavioral Health Clinic between November 1, 2014 and March 1, 2020 and met strict PANS criteria were retrospectively reviewed for study inclusion. 16 patients were excluded because they had no neurological exam within the first three visits and within three months of clinical presentation.

Main Outcomes and Measures

The following NSS-BG were recorded from medical record review: 1) glabellar tap reflex, 2) tongue movements, 3) milkmaid's grip, 4) choreiform movements, 5) spooning, and 6) overflow movements. We included data from prospectively collected symptoms and impairment scales.

Results

The study included 119 patients: mean age at PANS onset was 8.2 years, mean age at initial presentation was 10.4 years, 55.5% were male, and 73.9% were non-Hispanic White. At least one NSS-BG was observed in 95/119 patients (79.8%). Patients had 2.1 NSS-BG on average. Patients with 4 or more NSS-BG had higher scores of global impairment (p=0.052) and more symptoms (p=0.008) than patients with 0 NSS-BG. There was no significant difference in age at visit or reported caregiver burden. On Poisson and linear regression, the number of NSS-BG was associated with global impairment (2.857, 95% CI: 0.092-5.622, p=0.045) and the number of symptoms (1.049, 95% CI: 1.018-1.082, p=0.002), but not age or duration of PANS at presentation.

Conclusions and Relevance

We found a high prevalence of NSS-BG in patients with PANS and an association between NSS-BG and disease severity that is not attributable to younger age. PANS may have a unique NSS-BG profile, suggesting that targeted neurological exams may support PANS diagnosis.

Neurological Soft Signs and Clinical Features of Tic-Related Obsessive-Compulsive Disorder Indicate a Unique Subtype

Tic-related obsessive-compulsive disorder (OCD) may be a unique OCD subtype. This study examined whether neurological soft signs (NSSs) of patients with tic-related and tic-free OCD enable discrimination of these subgroups. We used the Neurological Evaluation Scale to assess 32 patients with tic-related and 94 with tic-free OCD, as well as 84 controls. Most patients with tic-related OCD were male, with earlier illness onset and poorer insight scores than those of patients with tic-free OCD. Patients with tic-related OCD had poorer motor coordination, sensory integration, and motor sequencing than did tic-free patients. Logistic regression using NSS subscale scores predicted tic-related OCD. Patients with tic-related OCD displayed greater neurodevelopmental abnormalities than did tic-free patients. NSSs of the former group suggest the need to separate this subgroup. Our results also support the newly introduced tic-related specifier in the fifth edition of the Diagnostic and statistical manual of mental disorders.

Motor dysfunction as research domain across bipolar, obsessive-compulsive and neurodevelopmental disorders

Although genuine motor abnormalities (GMA) are frequently found in schizophrenia, they are also considered as an intrinsic feature of bipolar, obsessive-compulsive, and neurodevelopmental disorders with early onset such as autism, ADHD, and Tourette syndrome. Such transnosological observations strongly suggest a common neural pathophysiology. This systematic review highlights the evidence on GMA and their neuroanatomical substrates in bipolar, obsessive-compulsive, and neurodevelopmental disorders. The data lends support for a common pattern contributing to GMA expression in these diseases that seems to be related to cerebello-thalamo-cortical, fronto-parietal, and cortico-subcortical motor circuit dysfunction. The identified studies provide first evidence for a motor network dysfunction as a correlate of early neurodevelopmental deviance prior to clinical symptom expression. There are also first hints for a developmental risk factor model of these mental disorders. An in-depth analysis of motor networks and related patho-(physiological) mechanisms will not only help promoting Research Domain Criteria (RDoC) Motor System construct, but also facilitate the development of novel psychopharmacological models, as well as the identification of neurobiologically plausible target sites for non-invasive brain stimulation.

Neurological soft signs, dissociation and alexithymia in patients with obsessive-compulsive disorder (OCD) and healthy subjects

A body of evidence has supported that patients with obsessive-compulsive disorder (OCD) have increased rates of various neurological soft signs (NSS) compared to controls. Various lines of research has documented robust relationships between OCD and dissociative symptomatology. The study aimed to examine the associations between obsessive-compulsive symptoms, dissociative experiences alexithymia, and NSS. The study included thirty OCD patients and thirty healthy controls, matched for age, marital status, education, and income. The Neurological Evaluation Scale (NES), Padua Inventory-Revised (PI-R), Dissociative Experiences Scale (DES) and Toronto Alexithymia Scale (TAS-20) were administered. In comparison to healthy controls, patients with OCD had difficulty sequencing for complex motor acts and greater absorption/ imaginative involvement. Using latent class analysis, the study sample was classified into two homogenous subsets as mild NSS (n = 45) and severe NSS (n = 15). Majority of the participants who were grouped into severe NSS latent class were OCD patient (n = 14, 93.3%). Furthermore, those with severe NSS reported greater levels of alexithymia and more severe obsessive-compulsive symptoms, particularly precision. We concluded that relationships between OCD severity and NSS appear to be of crucial importance. Our data along with accumulated evidence suggest that OCD associated with pronounced NSS may represent a specific subtype of the disorder.

Motor Abnormalities: From Neurodevelopmental to Neurodegenerative Through "Functional" (Neuro)Psychiatric Disorders

Background

Motor abnormalities (MAs) of severe mental disorders have been traditionally neglected both in clinical practice and research, although they are an increasing focus of attention because of their clinical and neurobiological relevance. For historical reasons, most of the literature on MAs has been focused to a great extent on schizophrenia, and as a consequence their prevalence and featural properties in other psychiatric or neuropsychiatric disorders are poorly known. In this article, we evaluated the extent to which catatonic, extrapyramidal and neurological soft signs, and their associated clinical features, are present transdiagnostically.

Methods

We examined motor-related features in neurodevelopmental (schizophrenia, obsessive compulsive disorder, autism spectrum disorders), "functional" (nonschizophrenic nonaffective psychoses, mood disorders) and neurodegenerative (Alzheimer's disease) disorders. Examination of the literature revealed that there have been very few comparisons of motor-related features across diagnoses and we had to rely mainly in disorder-specific studies to compare it transdiagnostically.

Results

One or more motor domains had a substantial prevalence in all the diagnoses examined. In "functional" disorders, MAs, and particularly catatonic signs, appear to be markers of episode severity; in chronic disorders, although with different degree of strength or evidence, all motor domains are indicators of both disorder severity and poor outcome; lastly, in Alzheimer's disease they are also indicators of disorder progression.

Conclusions

MAs appear to represent a true transdiagnostic domain putatively sharing neurobiological mechanisms of neurodevelopmental, functional or neurodegenerative origin.

Proposing the short Neurological Evaluation Scale

OBJECTIVES

The time required in completing the 26 items of neurological examinations in the standard Neurological Evaluation Scale (NES) may limit its utility in pragmatic clinical situations. We propose the Short Neurological Evaluation Scale (S-NES) for use in busy clinical settings, and in research.

METHODS

Using confirmatory factor analyses, we identified 12 items of neurological examination showing significant overlap with previously reported theoretical and empirical categories of neurological soft signs (NSS) in schizophrenia. This provided justification for the development of a shorter version of the NES based on the empirically identified NSS. In the present study, we relied on existing data to present an initial validation of the S-NES against the referent standard 26-item NES. We determined sensitivity, specificity, and likelihood ratios. Posterior-test probability was estimated using a Bayesian nomogram plot.

RESULTS

Using data derived from 84 unmedicated or minimally treated patients with first-episode schizophrenia, 12 empirically determined items of neurological examinations showed high agreement with the 26 items in the standard NES battery (sensitivity=96.3%, specificity=100%, and posterior-test probability=100%).

CONCLUSIONS

Within limitations of validity estimates derived from existing data, the present results suggest that the design of the S-NES based on empirically identified 12 items of neurological examination is a logical step. If successful, the S-NES will be useful for rapid screening of NSS in busy clinical settings, and also in research.

Behavioral Biomarkers of Schizophrenia in High Drinker Rats: A Potential Endophenotype of Compulsive Neuropsychiatric Disorders

Psychogenic polydipsia, which is compulsive, non-regulatory fluid consumption, is present in 6%-20% of chronic psychiatric patients and frequently associated with the schizophrenia diagnosis. In the present study, we investigated the relation between schizophrenia-like symptoms and biomarkers with a compulsive drinking behavior phenotype in rats. Rats that were selected for low drinking vs high drinking behavior following schedule-induced polydipsia (SIP) were assessed in a latent inhibition (LI) paradigm using tone and electrical foot shock and in a spatial reversal learning task to evaluate behavioral inflexibility. We also analyzed the myelin basic protein in different brain areas of high drinker (HD) and low drinker (LD) rats. The HD rats, which were characterized by a compulsive drinking behavior on SIP, had a reduced level of LI effect and increased behavioral inflexibility in the spatial reversal learning task in comparison to the LD group. Moreover, HD rats showed less myelination in the center of the corpus callosum, striatum, and amygdala in comparison to LD rats. These findings strengthen the validity of HD rats that were selected by SIP as a possible phenotype of compulsive neuropsychiatric disorders, as evidenced by the existence of behaviors and biological markers that are related to schizophrenia and obsessive-compulsive disorder, including a reduced LI effect, behavioral inflexibility and reduced brain myelination. Future studies could contribute to the elucidation of the mechanisms underlying the compulsive phenotype of HD rats and its relation to vulnerability to schizophrenia.

Comparison of Neurological Soft Signs between Psychotic and Non Psychotic Patients

INTRODUCTION

Neurological Soft Signs (NSS) are a group of non-specific signs manifested in some psychiatric patients. Till date, most studies have focused on NSS in schizophrenic patients.

AIM

In the current study, the mean NSS score was compared between psychotic and non psychotic patients.

MATERIALS AND METHODS

This descriptive analytical study was conducted on 96 hospitalized patients having psychotic disorders. The patients were first examined by a psychiatrist and their axis I diagnoses (according to DSM-IV-TR) were made. Accordingly, the patients were divided into three groups of psychotic (schizophrenic and schizoaffective) and bipolar disorder patients with and without psychotic symptoms. Using a 28-item questionnaire, the patients were neurologically examined and their NNS scores were calculated. The mean scores were compared among the groups.

RESULTS

Based on the results, the mean NSS score in psychotic patients (schizophrenic and schizoaffective) was higher as compared to that in non-psychotic patients (bipolar disorder patients without psychotic symptoms) and this difference was statistically significant (p<0.0001).

CONCLUSION

It seems that calculation of NSS score in psychotic patients can help predict the response to pharmaceutical treatment, risk of drug reactions/side effects and prognosis of disease. Drawing a definite conclusion in this regard requires further investigations.

A qualititative study of neurological soft signs in obsessive compulsive disorder and effect of comorbid psychotic spectrum disorders and familiality on its expression in Indian population

INTRODUCTION

Obsessive Compulsive Disorder (OCD) is one of the most common psychiatric disorders, with lifetime prevalence of 2%-3% and is known to lie on a spectrum continuous with Schizophrenia and other affective psychosis. Neurological Soft Signs (NSS) have been reported to be higher in both Schizophrenia and affective psychosis, like bipolar disorder, and their first degree relatives but in OCD, the results have been inconsistent. It remains unclear if NSS occur at even higher rates in individuals who have a co-morbidity for OCD and either schizophrenia or bipolar disorder, as it might be expected if a broader neurodevelopmental hit underlies the pathophysiology of both OCD and these disorders.

AIMS AND OBJECTIVES

To assess and compare NSS in patients of OCD, OCD with Psychotic spectrum disorders (OCD-PSD), first degree relatives of OCD (FDR of OCD) and healthy controls.

METHODOLOGY

90 subjects each were recruited in four groups- OCD, OCD-PSD, FDR of OCD and healthy controls, as per the pre-defined inclusion and exclusion criteria for each group. Diagnosis was made as per ICD-10 criteria and Cambridge Neurological Inventory, Part-2 was applied.

RESULTS AND CONCLUSION

This study found statistically significant difference between the severity of NSS among these groups. There was also a significant difference in presence of NSS in OCD with PSD group and OCD group. A greater abnormality of NSS in FDR of OCD compared to healthy controls was found. This difference in proportions and severity of NSS between groups points towards an underlying common neurobiological and etiopathological underpinning between OCD with and without comorbid PSDs and their first degree relatives.

Mild neurological impairment may indicate a psychomotor endophenotype in patients with borderline personality disorder

The aim of the present study was to determine whether patients with borderline personality disorder (BPD) show any neurological soft signs compared to healthy controls. Furthermore we sought to examine the role of common symptoms related to BPD, such as depression, anxiety or impulsivity, in association with neurological soft signs. Thirty patients with borderline personality disorder and thirty hospital-based controls were examined for neurological soft signs. The total score of neurological soft signs in BPD was significantly higher than controls. In terms of subscales, patients had higher scores in Sensory Integration and Motor Coordination and other neurological soft signs compared to control group. Multiple regression analysis showed that the impulsivity score was the best significant predictor of neurological soft signs in BPD. The increase of neurological soft signs in patients with BPD may address a non-focal neurological dysfunction in borderline personality disorder.

Neuropsychological, electrophysiological and neurological impairments in patients with obsessive compulsive disorder, their healthy siblings and healthy controls: Identifying potential endophenotype(s)

The etiology of obsessive-compulsive disorder (OCD) has not been clarified. This study aimed to investigate the cognitive, neurological, electrophysiological functions which are reflected in executive functions, memory, visuospatial integration; neurological examination and auditory event related potentials (AERP) (N100, N200, P200 and P300) in patients with OCD, their siblings, and control subjects and to determine potential endophenotypic markers. Thirty-three patients with OCD, 18 siblings and 21 controls; matched for age, gender and years of education were included. Yale Brown Obsessive Compulsive Symptoms Checklist Scale, Hamilton Depression-Rating Scale, an exhaustive neuropscyhological test battery and Neurological Evaluation Scale were administered. Their AERP recordings were obtained. Executive functions and visuospatial integration were highly impaired in patients and slightly in their siblings compared to controls. P200 amplitude was sorted as siblings>patients>controls. P300 amplitude was sorted as patients<siblings<controls. Neurological Evaluation Scale scores were lower in patients compared to siblings and controls. The logistic regression analysis showed that, higher P300 amplitude, better performance on block design test and faster completion of Stroop test would predict being in the control group, whereas higher P200 amplitude would predict being in the case (patient and sibling) groups. We suggest that these seem to be the potential endophenotypes of OCD.

Neurological soft signs in children with attention deficit hyperactivity disorder: Their relationship to executive function and parental neurological soft signs

The correlations between neurological soft signs (NSS) in children with attention deficit hyperactivity disorder (ADHD) and their executive function, symptoms of inattention, and hyperactivity-impulsivity and the NSS of their parents remain unclear. This study aimed to examine: (1) the prevalence of NSS in children with ADHD and their parents; (2) the correlation between the NSS of children with ADHD and the NSS of their parents; and (3) the correlation between the NSS of children with ADHD and their executive function and symptoms. NSS were assessed with the Cambridge Neurological Inventory (CNI) in 57 children with ADHD (and 80 parents) and 60 healthy children (and 75 parents). Executive function was measured with the Behavioral Rating Inventory of Executive Function (BRIEF). Children with ADHD and their parents had significantly higher NSS than normal children and their parents, respectively, and the NSS of children with ADHD were correlated more strongly with the NSS of their fathers than their mothers. No correlation was found between NSS and BRIEF executive function, but Disinhibition in children with ADHD was significantly correlated with hyperactivity-impulsivity symptoms. Paternal and maternal NSS provided different predictions for child NSS. It may be that NSS are more likely to be genetically transmitted by fathers.

Neurological soft signs in primary headache patients

Neurological soft signs (NSS) are semeiotic anomalies not assessed by the standard neurological examination, primarily developed in psychiatric settings and recently proposed as potential markers of minor brain circuit alterations, especially the cerebellar-thalamic-prefrontal network. Primary headache patients present with normal neurological examination and frequent psychiatric comorbidity. Aim of this exploratory study consisted in assessing NSS in 20 episodic frequent migraine (MH) and in 10 tension-type headache (ETTH) outpatients compared to 30 matched healthy controls. NSS were assessed by the Heidelberg scale; clinical characteristics and brain MRI were additionally obtained in all patients. NSS were increased by ∼70 and ∼90% in ETTH and MH, respectively, with respect to controls (p<0.001) and the difference remained significant even after controlling for age and education. Headache type and characteristics did not influence NSS presentation, while headache patients with white matter hyperintensities (WMH) at brain MRI had higher NSS scores compared both to normal controls and patients without WMH. NSS identify a subset of primary headache patients sharing the same comorbidities or minimal brain anomalies, suggesting that tailored prophylactic options might apply.

Patient-reported outcomes in obsessive-compulsive disorder

The purpose of the article was to provide an overview of patient-reported outcomes (PROs) and related measures that have been examined in the context of obsessive-compulsive disorder (OCD). The current review focused on patient-reported outcome measures (PROMs) that evaluated three broad outcome domains: functioning, health-related quality of life (HRQoL), and OCD-related symptoms. The present review ultimately included a total of 155 unique articles and 22 PROMs. An examination of the PROs revealed that OCD patients tend to suffer from significant functional disability, and report lower HRQoL than controls. OCD patients report greater symptom severity than patients with other mental disorders and evidence indicates that PROMs are sensitive to change and may be even better than clinician-rated measures at predicting treatment outcomes. Nonetheless, it should be noted that the measures reviewed lacked patient input in their development. Future research on PROMs must involve patient perspectives and include rigorous psychometric evaluation of these measures.

Neurological soft signs are not "soft" in brain structure and functional networks: evidence from ALE meta-analysis

BACKGROUND

Neurological soft signs (NSS) are associated with schizophrenia and related psychotic disorders. NSS have been conventionally considered as clinical neurological signs without localized brain regions. However, recent brain imaging studies suggest that NSS are partly localizable and may be associated with deficits in specific brain areas.

METHOD

We conducted an activation likelihood estimation meta-analysis to quantitatively review structural and functional imaging studies that evaluated the brain correlates of NSS in patients with schizophrenia and other psychotic disorders. Six structural magnetic resonance imaging (sMRI) and 15 functional magnetic resonance imaging (fMRI) studies were included.

RESULTS

The results from meta-analysis of the sMRI studies indicated that NSS were associated with atrophy of the precentral gyrus, the cerebellum, the inferior frontal gyrus, and the thalamus. The results from meta-analysis of the fMRI studies demonstrated that the NSS-related task was significantly associated with altered brain activation in the inferior frontal gyrus, bilateral putamen, the cerebellum, and the superior temporal gyrus.

CONCLUSIONS

Our findings from both sMRI and fMRI meta-analyses further support the conceptualization of NSS as a manifestation of the "cerebello-thalamo-prefrontal" brain network model of schizophrenia and related psychotic disorders.

Sensory and motor secondary symptoms as indicators of brain vulnerability

In addition to the primary symptoms that distinguish one disorder from the next, clinicians have identified, yet largely overlooked, another set of symptoms that appear across many disorders, termed secondary symptoms. In the emerging era of systems neuroscience, which highlights that many disorders share common deficits in global network features, the nonspecific nature of secondary symptoms should attract attention. Herein we provide a scholarly review of the literature on a subset of secondary symptoms––sensory and motor. We demonstrate that their pattern of appearance––across a wide range of psychopathologies, much before the full-blown disorder appears, and in healthy individuals who display a variety of negative symptoms––resembles the pattern of appearance of network abnormalities. We propose that sensory and motor secondary symptoms can be important indicators of underlying network aberrations and thus of vulnerable brain states putting individuals at risk for psychopathology following extreme circumstances.