Sinister psychotics. Left-handedness in schizophrenia and affective disorder

Foundations of a Functional Theory of Human Handedness

A functional theory of human handedness is introduced based on early childhood experiences and the neural plasticity of the brain. It assumes that very different factors may be involved in the development of an individual left-handedness. Imitation and social learning are major factors in the formation of both right- and left-handedness in normal early childhood development. However, the frequently claimed relation between left-handedness and pathology as well as exceptional giftedness can only be understood by taking into account the function or meaning of left-handedness for personality development. The functional approach conceives left-handedness as a ubiquitous symbolic aid for coping creatively with conflict in early childhood. A childrearing style that clashes with the child's body-mind needs can lead the socioculturally less favored left hand to serve as a symbolic frame of reference for a meaning-making action repertoire that is fundamental in protecting and stabilizing the childhood self and personality development. Suggestions are derived regarding brain lateralization and handedness and for the diagnosis of early childhood disorders.

Excess of non-right-handedness in schizophrenia: meta-analysis of gender effects and potential biases in handedness assessment

BACKGROUND

The notion that schizophrenia is characterised by increased non-right-handedness is a cornerstone of the theory that schizophrenia arises from, and is genetically linked to, abnormal brain lateralisation. Reviews and meta-analyses have reported higher rates of non-right-handers in patients with schizophrenia. However, this was suggested to be the result of a gender artefact or a hidden bias in self-report handedness questionnaires.

AIMS

To investigate using a meta-analytical approach whether the excess of non-right-handedness is seen in both females and males, and also when handedness is assessed behaviourally.

METHOD

Electronic databases were searched for studies that reported (a) the rate of female and male non-right-handers in schizophrenia compared with controls and (b) the rate of non-right-handers in schizophrenia (regardless of gender) based on behavioural handedness assessment.

RESULTS

The odds ratios (ORs) for females (OR = 1.63; based on 621 patients, 3747 controls) and males (OR = 1.50; based on 1213 patients, 3800 controls) differed significantly from 1.0, indicating both female and male patients were more often non-right-handed than controls. Moreover, there was an excess of non-right-handedness in patients with schizophrenia when handedness was assessed behaviourally: OR = 1.84 (1255 patients, 6260 controls). Even when both gender and behavioural handedness assessment were controlled for simultaneously, the excess of non-right-handedness persisted.

CONCLUSIONS

The findings clearly demonstrate that the excess of non-right-handedness in schizophrenia does not result from a gender artefact or from biased handedness questionnaires. It is a true empirical effect and may indeed reflect a genetic link between schizophrenia and brain lateralisation.

The interrelationships between moral attitudes, posttraumatic stress disorder symptoms and mixed lateral preference in Israeli reserve combat troops

BACKGROUND

Combat soldiers often encounter moral dilemmas during operational deployment, especially when an armed engagement is situated within a civilian setting. The study of moral dilemmas and posttraumatic stress disorder (PTSD) has mostly focused on the impact of war atrocities and moral injury. However, the relationship between moral attitudes and different combat-related pathologies has not been thoroughly addressed by quantitative studies.

AIMS

We aimed to assess the relationship between combatant's moral attitudes, severity of PTSD symptoms and mixed lateral preference.

METHODS

Data on moral objection, PTSD severity and lateral preference were collected in a right-handed non-pathologic sample (n = 147) of reserve combat troops in the Israel Defense Forces (IDF).

RESULTS

Nearly one-fifth (19.7%) of the reserve personnel who served in the occupied territories have reported high moral objection to the commands they were expected to act upon. This group of participants exhibited more PTSD symptoms and higher levels of mixed lateral preference. Multiple linear regression analyses revealed a mediating role of moral objection in the relationship between PTSD symptoms severity and lateral preference.

CONCLUSIONS

Our findings suggest that moral objection has significant implications on combatant's psychological and organic well-being. The findings highlight the need to include moral attitudes in research and clinical practice among combat personnel and veterans.

Description and Validation of a Flexible and Broadly Usable Handedness Questionnaire

Empirical evidence is provided which shows that handedness questionnaires should: (a) comprise items that cover skilled and unskilled activities; (b) be sufficiently long to capture a ''mass effect'' of variability in lateral preferences over a range of items; and (c) allow graded answer options for individual items rather than forced left/right choices. When using questionnaires that meet these criteria, it is possible to establish significant correlations between hand preference and performance even within a group of right-handers. In addition, such questionnaires are flexible enough to accommodate a great variety of handedness classification schemes.

Hand preference and hand skill in families with schizophrenia

Direction and degree of handedness in humans are variable between individuals and thought to be in part inherited. Several studies have shown an increase in non-right handedness among patients with schizophrenia, and some have included unaffected relatives. The present study was designed to determine whether reduced right handedness is more frequent among individuals with schizophrenia as compared with their well relatives and whether it clusters within families having multiple ill members. A total of 259 families comprising 418 individuals diagnosed with schizophrenia or schizoaffective disorder, 54 individuals with other psychoses, 145 family members with depression and other minor diagnoses, and 288 unaffected individuals were included. Hand preference was assessed by the Annett Scale and right relative to left hand skill measured using the Tapley-Bryden test. For all assessments of hand preference and hand skill, females were significantly more lateralised towards the right than males. Those individuals with schizophrenia or schizoaffective disorder had significantly less right hand preference than their unaffected relatives when measured as a quantitative index of items from the Annett Scale (p = .019), but not categorically (right, left or mixed). In contrast, there was no difference in hand skill between diagnostic groups. Hand preference was significantly correlated among male-male affected sibling pairs (p = .01) and similar results were found for hand skill among the total group of affected pairs (p = .001). Although these results only partially support a relationship between handedness and schizophrenia, they nevertheless draw attention to sex differences in hand preference and the familial aspects of hand preference in this disorder. More direct approaches to the genetics of cerebral dominance and psychosis are required.

Non-right-handedness is associated with migraine and soft bipolarity in patients with mood disorders

BACKGROUND

There is a substantial body of data showing differences in the functioning of the two hemispheres in unipolar depressive and bipolar disorders. Migraine is a frequent co-morbid disorder in these patients, and it has been proposed that migraine may be associated with left-handedness. It would therefore be interesting to study migraine and handedness in a population of patients with mood disorders.

METHODS

A total of 201 patients with an index episode of either major depression or mania were interviewed with a semi-structured interview based partly on DSM-IV criteria and partly on TEMPS-I for affective temperaments. The criteria of the Headache Classification Committee of the International Headache Society were used to establish the diagnosis of migraine. Hand preference was assessed using the Edinburgh inventory, and the patients were classified as having right-, left-, or mixed-handedness.

RESULTS

In the whole group 117 patients had migraine (58%) and 59 (29%) were classified as having non-right hand preference. There was a significant increased prevalence of non-right-handedness in the migraine group (37% vs. 19%, p=0.021, Chi-square test; OR 2.5; 95% CI 1.3 -4.8, p=0.007). In patients with cyclothymic, hyperthymic or irritable temperaments the prevalence of non-right-handedness (42%) was significantly higher (p=0.013, Chi-square test; OR 2.2, 95% CI 1.2-4.3) compared to patients with a depressive or no affective temperament (24%). The prevalence of non-right-handedness was also significantly higher both in patients with co-morbid eating disorders (48% vs. 26%, p=0.008 Chi-square test; OR 2.7, 95% CI 1.3-5.9, p=0.01) and asthma (45% vs. 26%, p=0.026 Chi-square test; OR 2.3, 95% CI 1.1-5.1, p=0.029).

LIMITATIONS

Non-blind evaluation of affective diagnosis, migraine and handedness.

CONCLUSIONS

Our main finding supports the hypothesis that non-right-handedness is associated with migraine and bipolar affective temperaments ("soft bipolarity") in a sample of patients with major affective disorders.

Lateralization of hand skill in bipolar affective disorder

Diverse strands of evidence suggest that schizophrenia is associated with an excess of left and mixed handedness, reflecting anomalous cerebral lateralization. Genetic studies have indicated a degree of overlap between bipolar disorder (BPD) and schizophrenia. Nevertheless, pattern of handedness and degree of lateralization have not been explicitly tested in BPD. We measured handedness, footedness and relative manual dexterity in a sample of 47 families comprising BPD probands and their bipolar-spectrum and unaffected relatives (N = 240). The BPD I sample (N = 55) was significantly more lateralized on handedness, footedness and relative manual dexterity than their unaffected relatives (N = 66). They were also more lateralized than their relatives with other psychiatric diagnoses. No evidence of excess mixed handedness or footedness was observed in the BPD I sample. We raise the possibility that schizophrenia and BPD I differ in that disproportionate left-hemisphere dominance in BPD I is associated with right-hemisphere dysfunction leading to deficits in emotional regulation. Given our results, we hypothesized that degree of lateralization may be a phenotypic marker or endophenotype for BPD I. We therefore conducted a family-based genetic association analysis with this quantitative trait. Relative hand skill was significantly associated with a functional variant in the catechol-O-methyltransferase gene. We speculate that this polymorphism may influence brain lateralization.

Mixed lateral preference in posttraumatic stress disorder

Recent research indicates that adults with posttraumatic stress disorder (PTSD) have a higher incidence of mixed laterality with respect to handedness than the rest of the population. To test if this relationship also occurs early in life, we evaluated children with history of interpersonal trauma. Fifty-nine traumatized children were evaluated with the Clinician Administered PTSD Scale for Children and Adolescents and the Edinburgh Handedness Inventory. Forty matched healthy controls were used for comparison. Increased mixed laterality was found in all children exhibiting symptoms of PTSD when compared with healthy controls, and children who met DSM-IV diagnostic criteria for PTSD had more mixed laterality than the subthreshold traumatized group (F = 7.71; df = 2,96; p = 0.001). Within the entire traumatized group, there was a positive correlation between PTSD symptom severity and mixed laterality. Mixed laterality was positively associated with PTSD symptoms in traumatized children, suggesting that neurological abnormalities may be related to degree of PTSD symptom expression.

Handedness in schizophrenia: a quantitative review of evidence

OBJECTIVE

The prevalence of various anomalous handedness subtypes in schizophrenia patients remains ambiguous. Although current literature favours the notion that the shift in lateral preferences seen is because of an increase of mixed-handedness, several studies suggest that exclusive left handedness is more prevalent than in the general population.

METHOD

Over 40 studies with reported prevalence data on various handedness subtypes in a schizophrenia population were evaluated by meta-analysis. Combined odds ratios for the three common handedness subtypes (left, mixed, and right) were separately calculated.

RESULTS

Each of the three atypical hand dominance patterns were significantly greater in schizophrenia patients than in control subjects, showing that the leftward shift in handedness distribution is not entirely because of an increase in mixed-handedness alone.

CONCLUSION

An increase of exclusive left-handedness is at variance with the prevailing assertion that the handedness shift in schizophrenia patients is because of a diffuse and bilateral hemispheric insult.

Childhood laterality and adult schizophrenia spectrum disorders: a prospective investigation

Left or mixed-handedness, footedness, and eye dominance are thought to indicate abnormalities in lateralization related to schizophrenia. Increased left or mixed-dominance in schizophrenia suggests possible hemispheric abnormalities associated with the disorder. A related body of research suggests that some indications of lateralization abnormalities may be evident prior to the onset of schizophrenia, suggesting that disruptions in lateralization are inherent to the developmental course of the disorder. We attempted to replicate and extend upon findings indicating differences in lateralization between children who later developed a schizophrenia spectrum disorder (n = 26) and those who did not develop a schizophrenia spectrum disorder (n = 216), among a high-risk and control, longitudinal sample. The rate of left or mixed-footedness, eye dominance, and any anomalous lateralization, but not handedness, discriminated between those who developed schizophrenia spectrum disorders and those who did not. Left or mixed-laterality appears to signal neurological disruption relevant to the development of schizophrenia spectrum disorders.

Sinistrality in subtypes of schizophrenia

Sinistrality, characterized by an excess of non-right-handedness, has been reported in schizophrenic patients, but the findings are controversial.

AIM

As sinistrality could be linked to a failure of hemisphere specialization in schizophrenia that would translate into language disorders, sinistrality was found out in disorganized and positive schizophrenic patients characterized by language disorders.

METHODS

Seventy-three schizophrenic patients (DSM IV) and 81 controls were evaluated with the Edinburgh Handedness Inventory (EHI). Patients were evaluated and classified into five subtypes (deficit, positive, disorganized, mixed and residual) with the Positive and Negative Syndrome Scale and the Schedule for the Deficit Syndrome.

RESULTS

Disorganized patients had a significantly more severe sinistrality in comparison to the deficit, residual and mixed subtypes and controls. A negative correlation was found between the disorganization and the EHI scores (r = - 0.34; P < 0.01). A significantly more severe sinistrality was also observed in the positive subtype in comparison to controls, but there was no correlation between hallucinatory and EHI scores (r = 0.06).

CONCLUSION

The findings provided further evidence that the defects in the normal process of lateralization observed in schizophrenia affects primarily disorganized patients.

Sinistrality in schizophrenia

Sinistrality characterized by an excess of non-right handedness has been reported in schizophrenic patients. Two factors, sex and kind of evaluation of handedness have contributed to major discrepancies across studies.

AIM

The hypothesis tested was that schizophrenic patients show a sinistral shift in handedness compared to controls taking into account the sex and using a continuum scoring system for evaluating handedness.

METHODS

Seventy-three (73.1% males) schizophrenic patients (DSMIV) and 81 (64.2% males) controls were evaluated with the Edinburgh Handedness Inventory (EHI [Neuropsychologia, 9 (1971) 97]).

RESULTS

The EHI score mean difference between patients with schizophrenia and control group was not significant when sex was taken into account.

CONCLUSION

Schizophrenic patients taken as a whole did not show a sinistral shift in handedness even if the sex and the continuum score for handedness were considered.

Handedness, language lateralisation and anatomical asymmetry in schizophrenia: meta-analysis

BACKGROUND

Cerebral lateralisation appears to be decreased in schizophrenia. Results of studies investigating this, however, are equivocal.

AIMS

To review quantitatively the literature on decreased lateralisation in schizophrenia.

METHOD

Meta-analyses were conducted on 19 studies on handedness, 10 dichotic listening studies and 39 studies investigating anatomical asymmetry in schizophrenia.

RESULTS

The prevalence of mixed- and left-handedness ('non-right-handedness') was significantly higher in patients with schizophrenia as compared to healthy controls, and also as compared to psychiatric controls. The analysis of dichotic listening studies revealed no significant difference in lateralisation in schizophrenia. However, when analysis was restricted to studies using consonant-vowel or fused word tasks, significantly decreased lateralisation in schizophrenia emerged. Asymmetry of the planum temporale and the Sylvian fissure was significantly decreased in schizophrenia, while asymmetry of the temporal horn of the lateral ventricle was not.

CONCLUSION

Strong evidence is provided for decreased cerebral lateralisation in schizophrenia.

Cerebral dominance and schizophrenia-spectrum disorders in adults with intellectual disability

Studies of the general population without intellectual disability have suggested an association between atypical handedness and schizophrenia-spectrum disorders (SSDs). Mixed handedness is taken as an index of diminished cerebral dominance or laterality. The present study addressed the question of whether such findings extend to the neurodevelopmentally 'at risk' population of adults with intellectual disability and SSDs compared with appropriate controls. Fourteen patients with a dual diagnosis of intellectual disability and SSD were compared with 14 controls with intellectual disability alone. Assessments of self-reported hand preference and relative hand skill were completed. Self-report of hand preference revealed highly significantly greater mixed-handedness in the SSD group. Furthermore, relative hand skill performance was significantly diminished for the dominant hand. The discrepancy between dominant and non-dominant hand functioning was lower in the SSD group and this association was highly significant. The results of the present study support the usefulness of such detailed laterality assessment in this population. Mixed laterality, over and above that of the population with general intellectual disability and developmental disorder, was associated with SSD. These results are consistent with the neurodevelopmental hypothesis of schizophrenia and its cognitive neuropsychiatric/neuropsychological sequelae.

Developmental instability and schizotypy

INTRODUCTION

It has been suggested that evidence of developmental disturbance of cognition and lateralisation in schizophrenia can be best understood from the perspective of developmental stability (DS), an indicator of the extent to which an individual develops according to a specified ontogenic programme in the presence of environmental noise. Higher levels of fluctuating asymmetry (FA; the difference between right and left side of a quantitative morphological trait such as dermatoglyphics) are thought to reflect less DS. We examined this issue for dimensions of schizotypy.

METHODS

Associations between FA, measures of laterality and cognitive function on the one hand, and negative and positive dimensions of schizotypy on the other, were examined in a sample of 260 healthy adolescents aged 11.9-15.6years. FA was measured as a-b ridge count right-left differences. Neuropsychological measures yielded a general cognitive ability score and a frontal function score. Laterality was assessed with the Annett scale.

RESULTS

Measures of psychosis proneness were normally distributed. Negative schizotypy was associated with more FA and lower general cognitive ability in a dose-response fashion. The association with FA was more apparent in boys. No associations existed with laterality or frontal function.

CONCLUSION

The negative dimension of schizotypy may be associated with early developmental instability, resembling the pattern seen in the negative symptom dimension of schizophrenia. Measures of fluctuating asymmetry may be more sensitive with regard to the schizotypy phenotype than measures of laterality.

Schizophrenic patients and their first-degree relatives show an excess of mixed-handedness

An excess of mixed-handedness in schizophrenia has been reported. However, it is not established whether this excess is manifest in non-schizophrenic psychoses, nor whether the underlying etiology is genetic or environmental. We investigated these issues in a group of patients with schizophrenia (n=94), affective psychosis (n=63), other psychosis (n=26); their respective first-degree relatives (total n=183) and a control group (n=85). A narrow definition of mixed-handedness was used corresponding to groups 5 and 6 as defined by the Annett Handedness Questionnaire. We found an excess of mixed-handedness in the schizophrenic group compared with controls (OR=5.2, 1.4-18.6, p<0.006). There was no difference between the other psychotic groups and controls. There was a trend for an excess of mixed-handedness in the first-degree relatives (n=99) of schizophrenic patients (p=0.055), but not in the relatives of affective or other psychotic patients. There was a striking linear trend in the proportion of mixed-handedness between controls, the relatives and the schizophrenic patients (chi2=7.0, p=0.008). There was no association between mixed-handedness and a history of pregnancy or birth complications in the schizophrenic group. There was some evidence for impaired sociability in the mixed-handed schizophrenic patients. Our results indicate that the excess of mixed-handedness in schizophrenia may have a genetic basis.

Response programming in patients with schizophrenia: a kinematic analysis

Schizophrenia may involve disturbed subcortical mechanisms or anomalous functional asymmetries. We therefore examined any anomalies of functional asymmetry in a kinematic analysis of a cued sequential movement task previously found to be sensitive to basal ganglia dysfunction. Twenty patients with schizophrenia and 20 matched controls used preferred or non-preferred hand to connect a series of targets on a WACOM SD420 graphics tablet, in response to the pattern of illumination of light emitting diodes (LEDs). Movements were to be initiated with or without an external cue as to target location. Patients with schizophrenia exhibited relatively normal functional asymmetries, but had programming deficits, taking longer to initiate (i.e. self generate) movements in the absence of an external cue. The movements of patients with schizophrenia were more variable and less efficient, resembling those seen in Huntington's disease. Results supported a hypothesis of disturbance at some level in fronto-subcortical circuitry in schizophrenia.

Schizophrenia Risk and Handedness: A Mixed Picture

Numerous previous studies have reported on handedness differences among schizophrenics, as well as in normal subjects who are high in ''schizotypal'' traits, and hence putatively at risk for schizophrenia. Results have varied, but there is evidence of a shift away from dextrality, especially consistent among schizotypal individuals. Using both a conventional three-category and Annett's seven-category classification of handedness, we re-examined the question in 681 general population subjects assessed for schizotypy. The three-category analysis confirmed previous findings of increased schizotypy in mixed-handers. However, the more fine-grained analysis showed that, although mild degrees of mixed handedness were indeed associated with increased schizotypy, this trend was reversed in the most mixed-handed subjects whose schizotypy scores did not differ significantly from right-handers. Independently of our work, this subgroup of mixed-handers are also reported to show superior intellectual function, especially on some spatial tasks. We concluded that previous studies of schizophrenia and schizotypy have failed to distinguish different reasons for shifts from dextrality. It is argued that the latter's association with schizophrenia might come about through exogenous, neurodevelopmental, influences, whereas some-possibly genetically basedforms of mixed handedness could reflect a variety of cerebral organisation that protects against, rather than enhances, the risk for mental disorder.

Side bias in schizophrenia: hand, foot, eye, and ear

Schizophrenics and normal controls were examined for their side (lateral) bias in terms of hand, foot, eye, and ear. Preference and performance measures were taken. The findings indicated a rightward bias for both measures in controls and in participants with schizophrenia. Side pattern was congruent between those with and without schizophrenia, with limb lateralization (hand, foot) orthogonal to sense-organ lateralization (eye, ear). Analysis of right- and left-side responses indicated a significant group difference for eye bias and ear bias as a function of response measures, preference, and performance.

Schizophrenia and autism considered as the products of an agnosic right shift gene

Crow (1995a) has argued that schizophrenia is caused by a gene associated with the evolution of human language and cerebral specialisation. This paper suggests a mechanism for Crow's theory which requires only one new assumption for the right shift genetic model of handedness and cerebral dominance (Annett, 1978). The proposal is that the RS+ allele, whose normal function is to induce the left hemisphere to serve speech by impairing speech-related cortex in the right hemisphere, tends to lose its directional coding. It becomes agnosic (RS+ a) for right versus left and impairs the left or right hemisphere at random. Schizophrenia is likely to develop when the RS+ a gene is paired with a normal RS+ gene but only in the 50% of cases where both hemispheres are affected. In the 50% where RS+ a affects the right hemisphere, development is normal as in the RS+ RS+ genotype. The risks for schizophrenia in monozygotic and dizygotic twins and other relatives are as expected for 50% expression of a Mendelian gene which is paired with a particular allele, but not alternative alleles at the same locus. The frequency of homozygotes for the agnosic gene is about 4 in 10,000, the rate observed for autism. A random pattern of double hemisphere deficits would give scope for a range of developmental strengths and weaknesses as observed within the spectrum of autistic disorders. Tests of the model require brain-imaging studies sensitive to individual differences in hemisphere lateralisation and a search for a genetic locus with human and nonhuman primate alleles, together with a mutant of the human form with a frequency of about 2%.