Clinical rating scales and instruments: how do they compare in assessing abnormal, involuntary movements?

Motor actions across psychiatric disorders: A research domain criteria (RDoC) perspective

The motor system is critical for understanding the pathophysiology and treatment of mental illness. Abnormalities in the processes that allow us to plan and execute movement in a goal-directed, context-appropriate manner (i.e., motor actions) are especially central to clinical motor research. Within this context, the NIMH Research Domain Criteria (RDoC) framework now includes a Motor Actions construct within the recently incorporated Sensorimotor Systems Domain, providing a useful framework for conducting research on motor action processes. However, there is limited available resources for understanding or implementing this framework. We address this gap by providing a comprehensive critical review and conceptual integration of the current clinical literature on the subconstructs comprising the Motor Actions construct. This includes a detailed discussion of each Motor Action subconstruct (e.g., action planning/execution) and its measurement across different units of analysis (e.g., molecules to behavior), the temporal and conceptual relationships among the Motor Action subconstructs (and other relevant RDoC domain constructs), and how abnormalities in these Motor Action subconstructs manifest in mental illness. Together, the review illustrates how motor system dysfunction is implicated in the pathophysiology of many psychiatric conditions and demonstrates shared and distinct mechanisms that may account for similar manifestations of motor abnormalities across disorders.

Neuromotor dysfunction as a major outcome domain of psychotic disorders: A 21-year follow-up study

BACKGROUND

The long-term stability of neuromotor domains assessed at the first episode of psychosis (FEP) and their ability for predicting a number of outcomes remains largely unknown, and this study addressed these issues.

METHODS

This was a longitudinal study of 243 participants with FEP who were assessed at baseline for background variables and parkinsonism, dyskinesia, neurological soft signs (NSS) and catatonia, and reassessed 21 years later for the same neuromotor variables, psychopathology, functioning, personal recovery, cognitive performance and medical comorbidity. Stability of neuromotor ratings was assessed using the intraclass correlations coefficient and associations between the predictors and outcomes were examined using univariate and multivariate statistics.

RESULTS

Baseline dyskinesia and NSS ratings showed excellent stability over time whereas that for parkinsonism and catatonia was relatively low. Neuromotor dysfunction at follow-up was independently predicted by a family history of schizophrenia, obstetric complications, neurodevelopmental delay, low premorbid IQ and baseline ratings of dyskinesia and NSS. Moreover, baseline dyskinesia and NSS ratings independently predicted more positive and negative symptoms, poor functioning and less personal recovery; catatonia predicted less personal recovery and more medical comorbidity. Baseline neuromotor ratings explained between 4% (for medical comorbidity) and 34% (for neuromotor dysfunction) of the variance in the outcomes. Lastly, neuromotor dysfunction at baseline highly predicted clinical staging at follow-up.

CONCLUSION

Baseline neuromotor domains show variable stability over time and relate distinctively to very long-term outcomes. Both baseline dyskinesia and NSS are trait markers of the disease process and robust predictors of the outcomes.

Graphomotor Dysfluency as a Predictor of Disease Progression in Premanifest Huntington's Disease

BACKGROUND

Prior studies have relied on conventional observer-based severity ratings such as the Unified Huntington's Disease Rating Scale (UHDRS) to identify early motor markers of decline in Huntington's disease (HD).

OBJECTIVE

The present study examined the predictive utility of graphomotor measures handwriting and drawing movements.

METHODS

Seventeen gene-positive premanifest HD subjects underwent comprehensive clinical, cognitive, motor, and graphomotor assessments at baseline and at follow-up intervals ranging from 9-36 months. Baseline graphomotor assessments were subjected to linear multiple regression procedures to identify factors associated with change on the comprehensive UHDRS index.

RESULTS

Subjects were followed for an average of 21.2 months. Three multivariate regression models based on graphomotor variables derived from a complex loop task, a maximum speed circle drawing task and a combined task returned adjusted R2 coefficients of 0.76, 0.71, and 0.80 respectively accounting for a significant portion of the variability in cUHDRS change score. The best-fit model based on the combined tasks indicated that greater decline on the cUHDRS was associated with increased pen movement dysfluency and stroke-stroke variability at baseline.

CONCLUSION

Performance on multiple measures of graphomotor dysfluency assessed during the premanifest or prodromal stage in at-risk HD individuals was associated with decline on a multidimensional index of HD morbidity preceding an HD diagnosis.

An Instrumental Measure of Hand and Facial Movement Abnormalities in Patients With Schizophrenia

INTRODUCTION

Movement disorders have been suggested to be a cardinal component of schizophrenia. With increased research interests in this area, instrumental measures are needed. This study was to examine if the motion capture system was reliable in measuring hand and facial bradykinesia and dyskinesia and more sensitive to detecting movement differences between schizophrenia patients and healthy people than traditional rating scales.

METHODS

Sixteen schizophrenia patients and 20 control subjects were recruited. Hand and facial bradykinesia and dyskinesia were measured using the motion capture system and rated using the Extrapyramidal Symptom Rating Scale and the Abnormal Involuntary Movement Scale.

RESULTS

The system showed strong test-retest reliability and generated larger effect sizes of group differences than did the rating scales.

CONCLUSIONS

The results may support researchers and clinical practitioners to apply the system to sensitively measuring the hand and facial movement symptoms in schizophrenia patients, which contributes to gaining a deep understanding of movement issues in schizophrenia.

Assessment of the Impact of Tardive Dyskinesia in Clinical Practice: Consensus Panel Recommendations

PURPOSE

Tardive dyskinesia (TD) is a hyperkinetic movement disorder in which patients experience abnormal involuntary movements that can have profound negative impacts on physical, cognitive, and psychosocial functioning. Use of measures to assess the functional impact of TD in routine clinical practice is lacking. To address this gap, an advisory panel of experts in psychiatry and movement disorder neurology was convened to develop consensus recommendations on assessment of the impact of TD on patients' functioning that can be used in clinical practice.

METHODS

An advisory panel provided recommendations using an iterative process, beginning with a narrative literature review regarding current practices for assessing the impact of TD in clinical settings. A detailed summary was generated, and the advisory panel provided comments about the content and answered questions about assessing TD impact in clinical practice. The panelists' responses were discussed during a virtual meeting held on August 28, 2020. A second meeting on September 25, 2020, focused on developing and refining recommendations for assessment of the impact of TD in clinical practice. At the conclusion of the second meeting, general consensus was reached on all recommendation statements.

RESULTS

As part of routine clinical practice, it is imperative to assess the impact of TD on the patient's life to help guide treatment decisions. Key domains for assessing the overall impact of TD include social, physical, vocational, and psychological functioning and the impact of TD on the underlying psychiatric disorder. Assessment of TD impact should be performed at every patient visit. Impact assessments should include consultation with patients, caregivers, and family members. Shared decision-making to initiate TD treatment should consider impact.

CONCLUSION

The impact of TD should be assessed routinely, including the key domains of social, physical, vocational, and psychological functioning and the impact of TD on the underlying psychiatric disorder.

Exploring Movement Impairments in Patients With Parkinson's Disease Using the Microsoft Kinect Sensor: A Feasibility Study

Background: Current assessments of motor symptoms in Parkinson's disease are often limited to clinical rating scales. Objectives: To develop a computer application using the Microsoft Kinect sensor to assess performance-related bradykinesia. Methods: The developed application (Motorgame) was tested in patients with Parkinson's disease and healthy controls. Participants were assessed with the Movement Disorder Society Unified Parkinson's disease Rating Scale (MDS-UPDRS) and standardized clinical side effect rating scales, i.e., UKU Side Effect Rating Scale and Simpson-Angus Scale. Additionally, tests of information processing (Symbol Coding Task) and motor speed (Token Motor Task), together with a questionnaire, were applied. Results: Thirty patients with Parkinson's disease and 33 healthy controls were assessed. In the patient group, there was a statistically significant (p < 0.05) association between prolonged time of motor performance in the Motorgame and upper body rigidity and bradykinesia (MDS-UPDRS) with the strongest effects in the right hand (p < 0.001). In the entire group, prolonged time of motor performance was significantly associated with higher Simson-Angus scale rigidity score and higher UKU hypokinesia scores (p < 0.05). A shortened time of motor performance was significantly associated with higher scores on information processing (p < 0.05). Time of motor performance was not significantly associated with Token Motor Task, duration of illness, or hours of daily physical activity. The Motorgame was well-accepted. Conclusions: In the present feasibility study the Motorgame was able to detect common motor symptoms in Parkinson's disease in a statistically significant and clinically meaningful way, making it applicable for further testing in larger samples.

Instrument-based assessment of motor function yields no evidence of dyskinesia in adult first-degree biological relatives of individuals with schizophrenia and schizoaffective disorder

There is accruing evidence of spontaneous dyskinesia in individuals with schizophrenia that is independent of medication exposure. Dyskinetic motor behavior is also present in individuals who are at high risk of schizophrenia and appears to have prognostic value for the development of psychosis. Nonetheless, it remains unclear whether dyskinesia is present in first-degree relatives of individuals with schizophrenia and thus associated with genetic liability for schizophrenia (i.e., an endophenotype), or whether the motor abnormality is a biomarker specific to the disease state spectrum. There is also limited information about links between dyskinesia and clinically relevant phenomena such as symptoms and cognition. Because dyskinesia marking genetic liability is likely to be subtle, we used sensitive instrument-based measurement of handwriting fluency to quantify dyskinesia in medicated individuals with schizophrenia or schizoaffective disorder, unaffected first-degree biological relatives of individuals with schizophrenia and schizoaffective disorder, and control participants. Results indicated that medicated individuals with schizophrenia or schizoaffective disorder exhibited more dyskinesia than both relatives and controls, with no difference between relatives and controls. Dyskinesia in individuals with schizophrenia or schizoaffective disorder was unrelated to current antipsychotic medication dosage, but associated with worse working memory function and greater positive formal thought disorder. These results provide evidence that dyskinesia is not associated with unexpressed genetic liability for schizophrenia.

Tardive dyskinesia: motor system impairments, cognition and everyday functioning

The recent approval of treatments for tardive dyskinesia (TD) has rekindled interest in this chronic and previously recalcitrant condition. A large proportion of patients with chronic mental illness suffer from various degrees of TD. Even the newer antipsychotics constitute a liability for TD, and their liberal prescription might lead to emergence of new TD in patient populations previously less exposed to antipsychotics, such as those with depression, bipolar disorder, autism, or even attention deficit hyperactivity disorder. The association of TD with activity limitations remains poorly understood. We review potential new avenues of assessing the functional sequelae of TD, such as the performance of instrumental activities of daily living, residential status, and employment outcomes. We identify several mediating aspects, including physical performance measures and cognition, that may represent links between TD and everyday performance, as well as potential treatment targets.

Distinguishing Patients With a Coordination Disorder From Healthy Controls Using Local Features of Movement Trajectories During the Finger-to-Nose Test

Assessment of coordination disorders is valuable for monitoring progression of patients, distinguishing healthy and pathological conditions, and ultimately aiding in clinical decision making, thereby offering the possibility to improve medical care or rehabilitation. A common method to assess movement disorders is by using clinical rating scales. However, rating scales depend on the evaluation and interpretation of an observer, implying that subjective phenotypic assignment precedes the application of the scales. Objective and more accurate methods are under continuous development but gold standards are still scarce. Here, we show how a method we previously developed, originally aimed at assessing dynamic balance by a probabilistic generalized linear model, can be used to assess a broader range of functional movements. In this paper, the method is applied to distinguish patients with coordination disorders from healthy controls. We focused on movements recorded during the finger-to-nose task (FNT), which is commonly used to assess coordination disorders. We also compared clinical FNT scores and model scores. Our method achieved 84% classification accuracy in distinguishing patients and healthy participants, using only two features. Future work could entail testing the reliability of the method by using additional features and other clinical tests such as finger chasing, quiet standing, and/or usage of tracking devices such as depth cameras or force plates.

Blink rate is associated with drug-induced parkinsonism in patients with severe mental illness, but does not meet requirements to serve as a clinical test: the Curacao extrapyramidal syndromes study XIII

BACKGROUND

Drug-induced parkinsonism (DIP) has a high prevalence and is associated with poorer quality of life. To find a practical clinical tool to assess DIP in patients with severe mental illness (SMI), the association between blink rate and drug-induced parkinsonism (DIP) was assessed.

METHODS

In a cohort of 204 SMI patients receiving care from the only mental health service of the previous Dutch Antilles, blink rate per minute during conversation was assessed by an additional trained movement disorder specialist. DIP was rated on the Unified Parkinson's Disease Rating Scale (UPDRS) in 878 assessments over a period of 18 years. Diagnostic values of blink rate were calculated.

RESULTS

DIP prevalence was 36%, average blink rate was 14 (standard deviation (SD) 11) for patients with DIP, and 19 (SD 14) for patients without. There was a significant association between blink rate and DIP (p < 0.001). With a blink rate cut-off of 20 blinks per minute, sensitivity was 77% and specificity was 38%. A 10% percentile cut-off model resulted in an area under the ROC curve of 0.61. A logistic prediction model between dichotomous DIP and continuous blink rate per minute an area under the ROC curve of 0.70.

CONCLUSIONS

There is a significant association between blink rate and DIP as diagnosed on the UPDRS. However, blink rate sensitivity and specificity with regard to DIP are too low to replace clinical rating scales in routine psychiatric practice.

TRIAL REGISTRATION

The study was started over 20 years ago in 1992, at the time registering a trial was not common practice, therefore the study was never registered.

The clinical and prognostic value of motor abnormalities in psychosis, and the importance of instrumental assessment

Motor abnormalities comprise several clinical signs intrinsic to psychosis. Critically, these features are of prognostic value in individuals at-risk for psychosis, and for those in early stages of psychotic disorders. Motor abnormalities such as tremor, rigidity, and neurological soft signs often go unrecognized. Currently, advances in this area are limited by a paucity of theoretical conceptions categorizing or linking these behaviours to underlying neurobiology affected in psychosis. However, emerging technological advances have significantly improved the ability to detect and assess motor abnormalities with objective instruments in a timely and reliable manner. Further, converging evidence has laid the groundwork for theoretically and empirically derived categorization and conceptualization. This review summarizes these advances, stressing the importance of motor abnormalities for understanding vulnerability across different stages of psychosis and introducing these innovative instrumental approaches. Patients, researchers and clinicians will benefit from these new developments, as better assessment aids the development of targeted interventions to ultimately improve the care for individuals experiencing psychosis.

Whole genome sequencing of one complex pedigree illustrates challenges with genomic medicine

Background

Human Phenotype Ontology (HPO) has risen as a useful tool for precision medicine by providing a standardized vocabulary of phenotypic abnormalities to describe presentations of human pathologies; however, there have been relatively few reports combining whole genome sequencing (WGS) and HPO, especially in the context of structural variants.

Methods

We illustrate an integrative analysis of WGS and HPO using an extended pedigree, which involves Prader–Willi Syndrome (PWS), hereditary hemochromatosis (HH), and dysautonomia-like symptoms. A comprehensive WGS pipeline was used to ensure reliable detection of genomic variants. Beyond variant filtering, we pursued phenotypic prioritization of candidate genes using Phenolyzer.

Results

Regarding PWS, WGS confirmed a 5.5 Mb de novo deletion of the parental allele at 15q11.2 to 15q13.1. Phenolyzer successfully returned the diagnosis of PWS, and pinpointed clinically relevant genes in the deletion. Further, Phenolyzer revealed how each of the genes is linked with the phenotypes represented by HPO terms. For HH, WGS identified a known disease variant (p.C282Y) in HFE of an affected female. Analysis of HPO terms alone fails to provide a correct diagnosis, but Phenolyzer successfully revealed the phenotype-genotype relationship using a disease-centric approach. Finally, Phenolyzer also revealed the complexity behind dysautonomia-like symptoms, and seven variants that might be associated with the phenotypes were identified by manual filtering based on a dominant inheritance model.

Conclusions

The integration of WGS and HPO can inform comprehensive molecular diagnosis for patients, eliminate false positives and reveal novel insights into undiagnosed diseases. Due to extreme heterogeneity and insufficient knowledge of human diseases, it is also important that phenotypic and genomic data are standardized and shared simultaneously.

Electronic supplementary material

The online version of this article (doi:10.1186/s12920-017-0246-5) contains supplementary material, which is available to authorized users.

Assessment of Drug-Associated Extrapyramidal Symptoms in People With Intellectual Disability: A Comparison of an Informant-Based Scale With Clinical Rating Scales

Drug-associated extrapyramidal symptoms (EPS) in people with intellectual disability (ID) may be difficult to recognize, and clinicians' assessments may be hampered by lack of patients' capacities to adequately cooperate and by lack of reliable instruments to measure EPS in this population. Therefore, we compared assessments based on professional caregivers' observations with the informant-based validated Matson Evaluation of Drug Side Effects (MEDS) scale with assessments by clinicians using a set of clinical rating scales, most of which have not been validated for use in this population. We also compared 2 dyskinesia scales by replacing the widely used but not validated Abnormal Involuntary Movement Scale with the validated Dyskinesia Identification System Condensed User Scale (DISCUS) in half of the set of scales. We used linear regression to analyze associations between EPS as measured with MEDS and EPS as measured with the sets of scales at item and at scale level.Of the 30 MEDS items, 6 were associated with items of the other scales. At scale level, we found no significant associations. Comparison of the Abnormal Involuntary Movement Scale with the DISCUS indicated that the DISCUS may be preferable for use in people with ID.Results may be explained by shortcomings in education and training of caregivers and by lack of reliable assessments and rating scales for EPS in people with ID.We conclude that there is an urgent need for education and training of care professionals and clinicians in this area and for studies investigating the psychometric properties of rating scales.

A quantitative measure of handwriting dysfluency for assessing tardive dyskinesia

Tardive dyskinesia (TD) is a movement disorder commonly associated with chronic exposure to antidopaminergic medications, which may be in some cases disfiguring and socially disabling. The consensus from a growing body of research on the incidence and prevalence of TD in the modern era of antipsychotics indicates that this disorder has not disappeared continues to challenge the effective management of psychotic symptoms in patients with schizophrenia. A fundamental component in an effective strategy for managing TD is its reliable and accurate assessment. In the present study, we examined the clinical utility of a brief handwriting dysfluency measure for quantifying TD. Digitized samples of handwritten circles and loops were obtained from 62 psychosis patients with or without TD and from 50 healthy subjects. Two measures of dysfluent pen movements were extracted from each vertical pen stroke, including normalized jerk and the number of acceleration peaks. Tardive dyskinesia patients exhibited significantly higher dysfluency scores than non-TD patients and controls. Severity of handwriting movement dysfluency was correlated with Abnormal Involuntary Movement Scale severity ratings for some tasks. The procedure yielded high degrees of test-retest reliability. These results suggest that measures of handwriting movement dysfluency may be particularly useful for objectively evaluating the efficacy of pharmacotherapeutic strategies for treating TD.

Evaluation of health promotion programmes in severe mental illness: theory and practice

Health promotion programmes for patients with severe mental illness (HPP) are not uniformly evaluated. We discuss the evaluation of HPP in theory and practice, as a prerequisite for future uniform evaluation. We explored the expected outcome and mechanism of HPP in the current literature. Based on this theoretical exploration we selected measures assessing the expected outcome and mechanism in current practice. The individual properties of these measures were described. Based on our theoretical exploration the outcome of HPP can be expressed in several aspects of health. Health can be improved through several mechanisms. In the current evaluation of HPP only some of the expected outcomes were evaluated. The measures used for evaluation were not all representative for the constructs they should assess. Important aspects of HPP are currently not evaluated, based on a comparison between our theoretical exploration of expected outcome and mechanism and current practice. Additionally, not all measures in use are suitable for evaluation of HPP. Therefore, development and identification of suitable measures is necessary. Our framework offers valuable directions for the development of such measures and the future evaluation of HPP.

Movement abnormalities predict transitioning to psychosis in individuals at clinical high risk for psychosis

Improving upon the predictive validity of determining the transition from high risk to actual psychosis is a primary aim of early intervention research. Previous research has suggested that premorbid spontaneous dyskinesias may be one possible predictor. In this study, dyskinetic movements were assessed with the Abnormal Involuntary Movement Scale (AIMS) at baseline of a longitudinal study of 148 individuals at clinical high risk (CHR) of developing psychosis. Twenty-eight individuals transitioned to a psychotic disorder over the course of the study. Group comparisons between transitioned and non-transitioned individuals indicated that, relative to those that were not observed to transition, participants that developed a psychotic disorder exhibited greater spontaneous dyskinesias at baseline. Moreover, increased dyskinetic movements at baseline resulted in a more than two-fold increase in odds of developing a psychosis for each point increase in AIMS scale score. These findings suggest that individuals with greater premorbid dyskinetic movements may comprise a subset of CHR individuals at inordinate risk to decompensate into psychosis. Future work should employ assessments of spontaneous dyskinesias by instrumentation (e.g., electromyography) and look to ascertain whether specific dyskinesias (e.g., dystonia) or dyskinesias of specific body regions are associated with transitioning to psychosis.

Movement disorders are associated with schizotypy in unaffected siblings of patients with non-affective psychosis

BACKGROUND

Movement disorders and schizotypy are both prevalent in unaffected siblings of patients with schizophrenia and both are associated with the risk of developing psychosis or schizophrenia. However, to date there has been no research into the association between these two vulnerability factors in persons with an increased genetic risk profile. We hypothesized that unaffected siblings of patients with non-affective psychosis have more movement disorders and schizotypy than healthy controls and that these co-occur.

METHOD

In a cross-sectional design we assessed the prevalence and inter-relationship of movement disorders and schizotypy in 115 unaffected siblings (mean age 27 years, 44% males) and 100 healthy controls (mean age 26 years, 51% males). Movement disorders were measured with the Abnormal Involuntary Movement Scale (AIMS), the Unified Parkinson Disease Rating Scale (UPDRS), the Barnes Akathisia Rating Scale (BARS), and one separate item for dystonia. Schizotypy was assessed with the Structured Interview for Schizotypy--Revised (SIS-R).

RESULTS

There were significant differences in the prevalence of movement disorders in unaffected siblings versus healthy controls (10% v. 1%, p<0.01) but not in the prevalence of schizotypy. Unaffected siblings with a movement disorder displayed significantly more positive and total schizotypy (p=0.02 and 0.03 respectively) than those without. In addition, dyskinesia correlated with positive schizotypy (r=0.51, p=0.02).

CONCLUSIONS

The association between movement disorders (dyskinesia in particular) with positive and total schizotypy in unaffected siblings suggests that certain vulnerability factors for psychosis or schizophrenia cluster in a subgroup of subjects with an increased genetic risk of developing the disease.

Movement disorders in nonpsychotic siblings of patients with nonaffective psychosis

Movement disorders such as dyskinesia and Parkinsonism have frequently been reported in (drug-naïve) patients with nonaffective psychosis. Therefore movement disorders may be related to schizophrenia. Siblings of patients with nonaffective psychosis also appear to have subtle forms of movement disorders. This suggests that motor abnormalities may also be related to the risk of developing the disease. Subtle forms are not always detected with the use of the standard observation-based clinical rating scales, which are less sensitive than mechanical instrument measurement. This study compared the presence and severity of dyskinesia and Parkinsonism in 42 non-psychotic siblings of patients with nonaffective psychosis and in 38 controls as measured by mechanical instruments and clinical rating scales. There were no significant differences in movement disorders between siblings and controls on the basis of clinical assessments. However, mechanical measurements indicated that siblings compared to controls displayed significantly more dyskinesia and Parkinsonism signs. These results suggest that motor signs could be markers of vulnerability for psychosis or schizophrenia. In addition this study shows that mechanical instrument measurement of movement disorders is more sensitive than assessment with clinical rating scales. Therefore, it may be used in screening programs for populations at risk for psychosis.

Dyskinesia and parkinsonism in antipsychotic-naive patients with schizophrenia, first-degree relatives and healthy controls: a meta-analysis

BACKGROUND

Several studies have reported the presence of dyskinesia and parkinsonism in antipsychotic-naive patients with schizophrenia as well as in their first-degree relatives. These movement disorders may therefore form an integral part of the illness and its (genetic) liability.

METHOD

A systematic search was conducted in the Medline, EMBASE, and PsychINFO databases to identify studies reporting on dyskinesia and parkinsonism assessed in antipsychotic-naive patients with schizophrenia (n = 213) and controls (n = 242) and separately in nonill first-degree relatives (n = 395) and controls (n = 379). Effect sizes were pooled using random-effect models to calculate odds ratios (ORs) to compare the risk of these movement disorders among patients and healthy relatives each with matched controls.

RESULTS

Antipsychotic-naive schizophrenia was found to be strongly associated with dyskinesia (OR: 3.59, 95% confidence interval [CI]: 1.53-8.41) and parkinsonism (OR: 5.32, 95% CI: 1.75-16.23) compared with controls. Dyskinesia and parkinsonism were also significantly more prevalent in healthy first-degree relatives of patients with schizophrenia as compared with healthy controls (OR: 1.38, 95% CI: 1.06-1.81, and OR: 1.37, 95% CI: 1.05-1.79, respectively).

CONCLUSION

The results suggest that movement disorders, and by inference abnormalities in the nigrostriatal pathway, are not only associated with schizophrenia itself but may also be related to the (genetic) risk of developing the disease.

Pelvic dyskinesia with an outstanding response to tetrabenazine

We report on a patient who presented an invalidating progressive pelvic dyskinesia while receiving different kinds of neuroleptic drugs for a psychiatric disorder. The clinical features and different drug-induced movement scales showed an outstanding improvement after tetrabenazine was started. To the best of our knowledge, this is the first case report of pelvic dyskinesia with good evolution and control of dyskinesias after treatment with tetrabenazine.

Mortality and tardive dyskinesia: long-term study using the US National Death Index

BACKGROUND

Whether the development of tardive dyskinesia leads to an increase in mortality is still unclear.

AIMS

To explore the relationship between tardive dyskinesia and mortality over a 10-year period, using the National Death Index.

METHOD

Death certificates were obtained from the National Death Index on 1621 people repeatedly assessed for tardive dyskinesia by trained raters. Variables with the potential for influencing survival time were also investigated.

RESULTS

Tardive dyskinesia was significantly associated with an increase in mortality (P<0.001), but this association became non-significant when drug course and age were entered in the regression analysis. Those who had taken only conventional antipsychotics were twice as likely to die compared with those taking atypical agents (P<0.02). For those aged 53-65 years, conventional agents were associated with a sevenfold increase in mortality.

CONCLUSIONS

Older individuals with tardive dyskinesia treated with conventional antipsychotics appear to have a shortened survival time.

Validity and reliability of the Simpson-Angus Scale (SAS) in drug induced parkinsonism in the elderly

BACKGROUND

Quantification of drug induced parkinsonism (DIP) for study purposes is difficult. The most often used Simpson Angus Scale (SAS) lacks proper clinimetric evaluation. The newer Schedule for Assessment of Drug-Induced Movement Disorders (SADIMoD) shows good clinimetric characteristics, but has not been used in published clinical studies, probably due to the complexity of the scale.

OBJECTIVES

To evaluate internal consistency and inter-rater reliability of the SAS and the correlation ot f the SAS with the parkinsonism subscale of the SADIMoD in elderly.

METHOD

Fifteen elderly diagnosed with DIP were recruited. The patients were assessed three times with the SAS by three independent investigators. The resident also performed the SADIMoD. Internal consistency was measured by Cronbach's alpha-coefficient, inter-rater variability was examined with weighted kappa values and percentage of agreement and correlation to SADIMoD by Spearman's correlation coefficient.

RESULTS

SAS demonstrated good internal consistency reliability (Cronbach's alpha coefficients 0.83). Inter-rater reliability for sum score was good. For individual items slight agreement on the item salivation and moderate to very good agreement on remaining items calculated by weighted kappa values was reached. We found 87-100% agreement on the individual items with acceptance of 1 point difference between raters. The SAS demonstrated acceptable correlation with the SADIMoD parkinsonism subscale scores (Spearman's rho = 0.66; p < 0.01).

CONCLUSION

The SAS appears to be a valid and by different instructed health care professionals easy to perform research tool to evaluate DIP.

Neuroleptic-induced movement disorders in a naturalistic schizophrenia population: diagnostic value of actometric movement patterns

Background

Neuroleptic-induced movement disorders (NIMDs) have overlapping co-morbidity. Earlier studies have described typical clinical movement patterns for individual NIMDs. This study aimed to identify specific movement patterns for each individual NIMD using actometry.

Methods

A naturalistic population of 99 schizophrenia inpatients using conventional antipsychotics and clozapine was evaluated. Subjects with NIMDs were categorized using the criteria for NIMD found in the Diagnostic and Statistical Manual for Mental Disorders – Fourth Edition (DSM-IV).

Two blinded raters evaluated the actometric-controlled rest activity data for activity periods, rhythmical activity, frequencies, and highest acceleration peaks. A simple subjective question was formulated to test patient-based evaluation of NIMD.

Results

The patterns of neuroleptic-induced akathisia (NIA) and pseudoakathisia (PsA) were identifiable in actometry with excellent inter-rater reliability. The answers to the subjective question about troubles with movements distinguished NIA patients from other patients rather well. Also actometry had rather good screening performances in distinguishing akathisia from other NIMD. Actometry was not able to reliably detect patterns of neuroleptic-induced parkinsonism and tardive dyskinesia.

Conclusion

The present study showed that pooled NIA and PsA patients had a different pattern in lower limb descriptive actometry than other patients in a non-selected sample. Careful questioning of patients is a useful method of diagnosing NIA in a clinical setting.

Predictors of neuroleptic-induced dyskinesia and parkinsonism: the influence of measurement methods and definitions

The accurate and objective measurement of abnormal, involuntary movements remains highly desirable, whether the movements are secondary to pharmacotherapy or an expression of the primary illness. In a previous study, we found that the prevalence of tardive dyskinesia in a sample of 100 subjects ranged from 28% when using the Abnormal Involuntary Movement Scale (AIMS) or the Dyskinesia Identification Scale, Condensed User Version (DISCUS) to 62% using an instrumental measurement (IM) of peripheral dyskinesia. The goal of this study was to examine the relationship between various risk factors for tardive dyskinesia as predictor variables, and the AIMS, DISCUS, and IMs of dyskinesia, tremor, and velocity of motor movement as dependent variables. The sample consisted of 100, mostly patients with schizophrenia. Poor performance on the Mini-Mental State Examination (MMSE) and increasing age were the most consistent predictors of dyskinetic and parkinsonian movements. Various predictors were associated with specific abnormal movements. Head injury was related to slower speed of motor movements and the total DISCUS score. A history of smoking was associated with less IM dyskinesia. For those with coexisting parkinsonism and dyskinesia, significant associations were found with head injury, diabetes mellitus, and an AIMS score of 2 or greater in 2 body areas. Various classes of psychotropic agents seemed to have little influence on the MMSE or the development of dyskinesia and parkinsonism. Increasing age and a lower score on the MMSE seem to be particularly helpful in gauging the risk for parkinsonian and dyskinetic movements.