Functional and structural correlates of abnormal involuntary movements in psychosis risk and first episode psychosis.

BACKGROUND: Abnormal involuntary movements (AIM) may occur throughout the course of psychosis. While AIM are thought to indicate striatal abnormalities, the functional and structural correlates of increased AIM remain elusive. Here, we examined the prevalence of AIM in patients with clinical high risk for psychosis (CHR), first episode psychosis (FEP) and clinical controls (CC). Furthermore, we tested the association of AIM with regional cerebral blood flow (rCBF), grey matter volume (GMV), and premorbid IQ. METHODS: We conducted a video-based analysis of AIM in patients with CHR (n = 45), FEP (n = 10) and CC (n = 39), recruited in the Early Detection and Intervention Center, Bern. Premorbid intelligence was evaluated using the Peabody Picture Vocabulary test. Additionally, arterial spin labeling MRIs and structural MRIs were acquired in a subgroup of the sample to investigate the association of AIM with rCBF and GMV. RESULTS: Higher total AIM scores were detected in CHR (p = 0.02) and FEP (p = 0.04) as compared to CC. When separated for different muscle groups, lips and perioral movements were significantly increased in CHR patients as compared to CC (p = 0.009). AIM scores correlated positively with rCBF in the premotor cortex, Brodmann area 6 (p < 0.05, FWE corrected). Negative correlations were found between AIM and GMV of the corresponding caudal middle frontal gyrus (p = 0.04, FWE corrected) and premorbid intelligence (p = 0.02). CONCLUSIONS: AIM were more frequent in the psychosis spectrum than in clinical controls. Neuroimaging findings indicate an involvement of cortical motor areas in abnormal motor behavior, instead of pure basal ganglia pathology.

Nonverbal Hand Movement Durations Indicate Post-Concussion Symptoms of Athletes.

Methods of post-concussion diagnosis are still under debate with regard to sensitivity, objectivity, reliability, and costs. Spontaneous displays of nonverbal hand movement behavior during interaction are indicative of psychopathology and are relatively simple to record and analyze. Increased continuous (irregular) body-focused hand movement activity in particular indicates psychopathologies that overlap in symptomatology with those of sport-related concussions (SRCs). We therefore hypothesized that the duration of "irregular," "on body," and "act on each other" hand movements is increased in athletes with SRC who suffer from post-concussion symptoms. Three matched groups of 40 athletes were investigated: 14 symptomatic athletes with a concussion, 14 asymptomatic athletes with a concussion, and 12 non-concussed athletes. Using the Neuropsychological Gesture (NEUROGES)-Elan analysis system, four certified raters analyzed all nonverbal hand movements that were displayed during a videotaped standardized anamnesis about concussion history, incidence, course of action, and post-concussion symptoms. The duration of irregular Structure units among symptomatic athletes was significantly longer compared with asymptomatic athletes. Irregular, on body, and act on each other hand movement durations correlated with post-concussion symptoms. Whereas the duration of irregular units significantly predicted the post-concussion symptom score, working memory performances showed only marginal effects. Increased duration of irregular hand movement units indicates post-concussion symptoms in athletes with SRC. Because the recording of spontaneous displays of nonverbal hand movement behavior is relatively simple and cost efficient, we suggest using the neuropsychological analysis of hand movement behavior as a future diagnostic parameter of concussion management protocols.

Resveratrol Protects Against Vacuous Chewing Movements Induced by Chronic Treatment with Fluphenazine.

Typical antipsychotics, which are commonly used to treat schizophrenia, cause motor disorders such as tardive dyskinesia (TD) in humans and orofacial dyskinesia (OD) in rodents. The disease mechanisms as well as treatment effectiveness are still unknown. In this study, we investigated the effect of resveratrol, a polyphenol with neuroprotective properties, on behavioral changes induced by chronic treatment with fluphenazine in rats and the possible relationship between monoamine oxidase (MAO) activity and vacuous chewing movements (VCMs). Rats were treated for 18 weeks with fluphenazine enantate [25 mg/kg, intramuscularly (i.m.), every 21 days] and/or resveratrol (20 mg/kg, offered daily in drinking water). Next, body weight gain, behavioral parameters (VCMs and open field tests-locomotor and rearing activity), and MAO activity were evaluated. Fluphenazine treatment reduced body weight gain, number of crossings and rearings, and the co-treatment with resveratrol did not affect these alterations. Fluphenazine increased the prevalence and intensity of VCMs and the co-treatment with resveratrol reduced the VCMs. Furthermore, a negative correlation was found between the number of VCMs and MAO-B activity in the striatum of rats. Our data suggest that resveratrol could be promissory to decrease OD. Moreover, MAO-B activity in the striatum seems to be related to VCMs intensity.

Instrumental measurements of spontaneous dyskinesia and schizotypy in subjects with auditory verbal hallucinations and healthy controls.

Spontaneous dyskinesia is associated with non-affective psychosis. Few studies investigated dyskinesia in individuals with subclinical psychotic experiences. We examined dyskinesia using instrumental measurements of force variability in 34 individuals with frequent auditory verbal hallucinations but without a clinical psychotic disorder and 31 matched healthy controls. Schizotypy was assessed using the Schizotypal Personality Questionnaire. We found a positive correlation between dyskinesia and schizotypy in the total group. In addition, when using a cut-off point based on the 95th percentile of force variability in the control group, we found a greater proportion of subjects with dyskinesia in the group with auditory verbal hallucinations than in the control subjects. Current findings are in agreement with the concept of psychosis as a continuous phenomenon and with movement disorders being an integral part of psychosis.

Functional movement disorder: a long journey to diagnosis.

A 61-year-old man presented to a country clinic with involuntary orofacial movements and progressive cognitive decline, causing significant disability and psychosocial distress. Review of records uncovered a 7-year history of presentations to several specialties, including memory clinics, neurology, internal medicine and emergency departments, with varied symptoms, extensive complex work up and inconclusive diagnosis. Comprehensive review at our hospital highlighted inconsistent neurological signs, fluctuating cognition and psychosocial stressors, which preceded symptom onset, leading to the diagnosis of a functional movement disorder (FMD), which subsequently improved with relaxation therapy, cognitive-behavioural therapy and physiotherapy. We illustrate a variety of somatic symptoms, diagnostic clues and management outcomes for FMDs, and the importance of diagnostic criteria to minimise costly, time-consuming and ultimately unnecessary tests of exclusion.

Young adults with dyskinetic cerebral palsy improve subjectively on pallidal stimulation, but not in formal dystonia, gait, speech and swallowing testing.

BACKGROUND: Pharmacological treatment of dyskinetic cerebral palsy (CP) is often ineffective. Data about outcome of deep brain stimulation (DBS) in these patients remains scarce. METHODS: Eight patients with dyskinetic CP and DBS of the Globus Pallidus internus were investigated. Using pre- and postoperative videos the severity of dystonia and changes thereof during standardized settings ('on') and after the stimulator had been switched off ('off') were assessed using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). Furthermore, subjective impression (SI) of the extent of postoperative change as well as gait (Leonardo Mechanograph® Gangway), speech (Frenchay Dysarthria) and swallowing performances (fiberoptic laryngoscopy) were assessed during 'on' and 'off'. RESULTS: When comparing pre- and postoperative as well as 'on' and 'off', the BFMDRS and most of the gait, speech, and swallowing parameters did not differ significantly. In contrast, patients reported significant improvement of their SI postoperatively (3.1 on a 10-point-scale). CONCLUSION: Data show that our CP-patients did not benefit from GPi-DBS when tested formally for dystonia, gait, speech and swallowing. In stark contrast, these patients reported significant subjective improvement. Taken together, and in light of current unsatisfactory medical treatment options, our data suggest that further assessment of the effects of GPi-DBS in dyskinetic CP is warranted.

[Movement disorders is psychiatric diseases]. / Mozgászavarok pszichiátriai betegségekben.

Movement disorders are common in psychiatry. The movement disorder can either be the symptom of a psychiatric disorder, can share a common aetiological factor with it, or can be the consequence of psychopharmacological therapy. Most common features include tic, stereotypy, compulsion, akathisia, dyskinesias, tremor, hypokinesia and disturbances of posture and gait. We discuss characteristics and clinical importance of these features. Movement disorders are frequently present in mood disorders, anxiety disorders, schizophrenia, catatonia, Tourette-disorder and psychogenic movement disorder, leading to differential-diagnostic and therapeutical difficulties in everyday practice. Movement disorders due to psychopharmacotherapy can be classified as early-onset, late-onset and tardive. Frequent psychiatric comorbidity is found in primary movement disorders, such as Parkinson's disease, Wilson's disease, Huntington's disease, diffuse Lewy-body disorder. Complex neuropsychiatric approach is effective concerning overlapping clinical features and spectrums of disorders in terms of movement disorders and psychiatric diseases.

How to detect the yips in golf.

The yips is a multi-aetiological phenomenon that is characterized by an involuntary movement that can affect a golfer's putting performance. Diagnostics are crucial for a better understanding of what causes the yips but are still lacking. The purpose of the present study was therefore to identify sensitive methods for detecting the yips and evaluating its aetiology. Forty participants, 20 yips-affected golfers and 20 nonaffected golfers, completed a psychometric testing battery and performed a putting session in the laboratory. They answered questions about their golfing and yips experience and filled in standardized questionnaires measuring trait anxiety, perfectionism, stress-coping strategies, somatic complaints, and movement and decision reinvestment. In the laboratory, they had to putt in five different conditions that might elicit the yips: as usual with both arms, under pressure, with one (the dominant) arm, with a unihockey racket, and with latex gloves. Measures included putting performance, situational anxiety, kinematic parameters of the putter, electromyography of the arm muscles, and electrocardiography. The groups were separated only by putting performance and kinematic parameters when putting with the dominant arm. Future research should use kinematics to investigate the aetiology of the yips and possible interventions.

Spiral drawing during self-rated dyskinesia is more impaired than during self-rated Off.

OBJECTIVE: The purpose of this study was to examine repeated measures of fine motor function in relation to self-assessed motor conditions in Parkinson's disease (PD). METHODS: One-hundred PD patients, 65 with advanced PD and 35 patients with different disease stages have utilized a test battery in a telemedicine setting. On each test occasion, they initially self-assessed their motor condition (from 'very off' to 'very dyskinetic') and then performed a set of fine motor tests (tapping and spiral drawings). RESULTS: The motor tests scores were found to be the best during self-rated On. Self-rated dyskinesias caused more impaired spiral drawing performance (mean = 9.8% worse, P < 0.001) but at the same time tapping speed was faster (mean = 5.0% increase, P < 0.001), compared to scores in self-rated Off. CONCLUSIONS: The fine motor tests of the test battery capture different symptoms; the spiral impairment primarily relates to dyskinesias whereas the tapping speed captures the Off symptoms.

Stimulation of the subthalamic nucleus at an earlier disease stage of Parkinson's disease: concept and standards of the EARLYSTIM-study.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an established treatment for advanced Parkinson's disease (PD) with disabling motor complications. However, stimulation may be beneficial at an earlier stage of PD when motor fluctuations and dyskinesia are only mild and psychosocial competence is still maintained. The EARLYSTIM trial was conducted in patients with recent onset of levodopa-induced motor complications (≤ 3 years) whose social and occupational functioning remained preserved. This is called 'early' here. The study was a randomized, multicenter, bi-national pivotal trial with a 2 year observation period. Quality of life was the main outcome measure, and a video-based motor score was a blinded secondary outcome of the study. Motor, neuropsychological, psychiatric and psychosocial aspects were captured by established scales and questionnaires. The patient group randomized here is the earliest in the disease course and the youngest recruited in controlled DBS trials so far. The methodological innovation for DBS-studies of this study lies in novel procedures developed and used for monitoring best medical treatment, neurosurgical consistency, best management of stimulation programming, blinded video assessment of motor disability, and prevention of suicidal behaviors.

Efectos secundarios del tratamiento antipsicótico en niños y adolescentes naïve o quasi-naïve: diseño de un protocolo de seguimiento y resultados basales / Secondary effects of antipsychotic treatment in naive or quasi-naive children and adolescents: Design of a follow-up protocol and baseline results

Introducción. La prescripción de fármacos antipsicóticos en niños y adolescentes se ha convertido en una práctica habitual. Métodos. Este artículo presenta el diseño de un estudio multicéntrico longitudinal a 12 meses con 266 niños y adolescentes a los que se les prescribió por primera vez un antipsicótico de primera o segunda generación y los resultados basales del estudio. El protocolo de seguimiento tuvo como finalidad detectar la posible aparición de cambios metabólicos, cardiológicos y motores. Resultados. Cuando se valoró la presencia de efectos secundarios a través de la UKU (Udvalg für Kliniske Undersogelser) se encontraron diferencias estadísticamente significativas entre pacientes naïve (pacientes incluidos que nunca habían tomado antipsicótico) y quasi-naïve (aquellos que habían tomado antipsicóticos durante un periodo inferior a 30 días), mostrando un mayor número de estos últimos síntomas de: ansiedad/laxitud/fatigabilidad (p=0,0049), somnolencia/sedación (p<0,001), aumento duración sueños (p<0,001), aumento de sueños (p=0,0199), indiferencia emocional (p=0,0194), hipocinesia/acinesia (p=0,0224), parestesias (p=0,0049), trastorno de acomodación (p=0,0254), aumento de la salivación (p<0,001), poliuria/polidipsia (p=0,0076), aumento de la sudoración (p=0,0076), aumento del deseo sexual (p=0,0117), disminución del deseo sexual (p=0,0053), cefaleas tensionales. (p=0,0405). Cuando se valoró la presencia de síntomas extrapiramidales con la MPRC-IMS (Maryland Psychiatry Research Center-Involuntary Movements Scale) se observó que los pacientes quasi-naïve presentaron un número estadísticamente superior de síntomas de discinesia (p=0,002), parkinsonismo (p=0,0004) y acatisia (p=0,0437) con respecto a los naïve. Conclusiones. Estos resultados ponen de manifiesto que en población infanto-juvenil, la presencia de efectos secundarios se comienza a observar ya desde el inicio de la toma de fármacos antipsicóticos(AU)

Introduction. The prescribing of anti-psychotic drugs has become a normal clinical practice. Methods. This article presents a longitudinal, multicentre 12-months-long study conducted on 266 children and adolescents who were prescribed a first or second generation antipsychotic drug for the first time, and the baseline results of the study. The follow-up protocol had its purpose to detect the possible appearance of metabolic, cardiological, and motor changes. Results. When the presence of side effects was evaluated using the UKU (clinical side-effects scale) statistically significant differences were found between naïve (patients who had never taken an anti-psychotic drug) and quasi-naïve patients (those who have taken anti-psychotic drugs for a period of less than 30 days), with a greater number of the latter showing symptoms of: anxiety/laxity/tiredness (P=0.0049), drowsiness/sedation (P<0.001), increase in dream duration (P<0.001), increase in dreams (P=0.0199), emotional indifference (P=0.0194), hypokinesia/akinesia (P=0.0224), paresthesias (P=0.0049), accommodation disorder (P=0.0254), increase in salivation (P<0.001), polyuria/polydipsia (P=0.0076), increase in sweating (P=0.0076), increase in sexual desire (P=0.0117), decrease in sexual desire (P=0.0053), tension headaches (P=0.0405). When the presence of extrapyramidal symptoms was assessed using the MPRC-IMS (Maryland Psychiatry Research Center-Involuntary Movement Scale), it was observed that the quasi-naïve patients had a statistically higher number of dyskinesia (P=0.002), Parkinsonism (P=0.0004) and akathisia (P=0.0437) symptoms compared to the naïve patients. Conclusions. These results show that, in the childhood-adolescent population, the presence of secondary effects begins to be observed from the first dose of the antipsychotic drug(AU)

Parent-reported participation in children with cerebral palsy: the contribution of recurrent musculoskeletal pain and child mental health problems.

AIM: The aim of the study was to explore the contribution of recurrent musculoskeletal pain and mental health to aspects of participation in children with cerebral palsy (CP). METHOD: A total of 105 participants (54 males, 51 females); mean age 14 y (SD 3) were assessed by clinical examination, interview, and parental questionnaires. CP type distribution was as follows: spastic unilateral, 37%; spastic bilateral, 56%; and dyskinetic, 7%. Motor function assessed using the Gross Motor Function Classification System was level I, 33%; level II, 40%; level III, 15%; and level IV/V, 11%. Parents reported child participation using the Assessment of Life Habits, child mental health problems using the Strengths and Difficulties Questionnaire, their own mental health using the General Health Questionnaire, and their socioeconomic status. RESULTS: Recurrent musculoskeletal pain was associated with reduced accomplishment of daily activities (B=-1.22, p=0.02) and social roles (B=-1.17, p=0.03), and with reduced parental satisfaction with the accomplishment of daily activities (B=-1.14, p=0.03) and social roles (B=-1.48, p<0.01). Increasing levels of child mental health problems was associated with reduced accomplishment of daily activities (B=-0.10, p=0.02) and social roles (B=-0.11, p<0.01), and with reduced parental satisfaction with the accomplishment of social roles (B=-0.21, p<0.01). INTERPRETATION: Pain and child mental health should be considered in most participation models in CP. Regarding participation as an objective outcome measure is questionable.

[Anti-NMDA receptor encephalitis: a neurological and psychiatric emergency]. / Anti-NMDA-Rezeptor-Enzephalitis: Ein neurologisch-psychiatrischer Notfall.

Anti-NMDA receptor encephalitis is a severe autoimmune disease, first described in 2007.  Since then a number of cases have been published, suggesting that to date the disease is a considerably underdiagnosed entity. The clinical picture develops over a relatively long period of time and is initially characterised by psychiatric symptoms such as decreased levels of consciousness and hallucinations as well as paranoid behaviour. In the course of the disease neurological symptoms occur, in particular, seizures, autonomic dysfunction and dyskinesias. Due to the young age of many patients, the symptoms are often mistaken as to result from drug-induced psychosis. Anti-NMDA receptor Encephalitis was first described in young women with teratomas. In the past few years the disorder has also been reported in men and children and without any detectable neoplasia. The diagnosis is based on the characteristic clinical picture and supportive findings in MRI, EEG and the cerebrospinal fluid. Hereby, highly specific autoantibodies directed against the NR1 subunit of the NMDA-type glutamate receptors in the CSF (or serum) play an important role and should be sought specifically in any case of an "encephalitis of unknown cause". The prognosis of the disease is favourable, even when autonomic disorders entail ventilation and/or prolonged intensive care treatment is necessary. Nonetheless, the clinical outcome is highly dependent on an early diagnosis and immunotherapy without delay. In the case of a malignancy, tumour removal is also crucial. Taken together, an interdisciplinary approach including neurologists, psychiatrists, oncologists and gynaecologists is essential in order to detect and effectively treat this disorder.

Assessing self-awareness of dyskinesias in Parkinson's disease through movie materials.

The aim of our study was to determine self-awareness of dyskinesias and other core motor symptoms in Parkinson's disease (PD) through the use of movie presentations. A scale based on 10 movies (five depicting dyskinesias and five showing core symptoms) and the Self-Assessment Parkinson's Disease Disability Scale were administered to 21 patients (all with a Mini-Mental State Examination - MMSE score ≥ 25). Neurological assessment included the Unified Parkinson's Disease Rating Scale and the Hoehn-Yahr and Schwab-England scales. In addition, the MMSE, Beck Depression Inventory and Stroop task were administered. Overall, patient and caregiver ratings of dyskinesias and core PD symptoms were consistent. Two patients (9%) completely denied dyskinesias, while four patients (19%) significantly underestimated their dyskinesias. Our results confirm that poor self-awareness of symptoms in PD may be selective and that denial of dyskinesias affects only a minority of patients with normal cognitive status (MMSE ≥ 25). Most patients are aware of the presence of dyskinesias. Poor self-awareness of dyskinesias is associated with longer disease duration.

Evaluation of the routine clinical use of the Brief Psychiatric Rating Scale (BPRS) and the Abnormal Involuntary Movement Scale (AIMS).

OBJECTIVE: To evaluate the routine clinical use of the Brief Psychiatric Rating Scale (BPRS) (in psychiatrists' monthly notes) and the Abnormal Involuntary Movement Scale (AIMS) (done at admission and annually) in a state hospital. METHODS: Two residents and a medical student were trained in the use of the BPRS and the AIMS. These "key raters" then rated 21 patients before and 28 patients after the ward psychiatrists had one retraining session on the BPRS. These raters' results were compared with the ward psychiatrists' results before and after the BPRS retraining as well as with the ward psychiatrists' annual AIMS ratings. RESULTS: The key raters had high correlations among themselves (0.85 for total BPRS and a mean of 0.83 for individual BPRS items), but the correlations with the ward psychiatrists' ratings were very low (0.17 for total BPRS and a mean of 0.37 for individual BPRS items), and those correlations improved only slightly after the retraining of the ward psychiatrists (0.33 for total BPRS and a mean of 0.41 for individual BPRS items). Ward psychiatrists both missed tardive dyskinesia and labelled parkinsonism as tardive dyskinesia. CONCLUSIONS: The BPRS and AIMS are useful, practical rating scales, but if they are to be used routinely in clinical care, users must be regularly trained and retrained and rating performance evaluated. (Journal of Psychiatric Practice 2011;17:300-303).

Abnormal movements are associated with poor psychosocial functioning in adolescents at high risk for psychosis.

The period immediately preceding the onset of overt psychosis is characterized by a range of symptoms and behaviors including emerging attenuated psychosis, spontaneous movement abnormalities, and a broad decline in role and social functioning. Recent evidence suggests that basal ganglia dysfunction, which is implicated in the development of psychotic symptomatology, may manifest in the form of both movement abnormalities and deficits in processes integral to psychosocial functioning. However, little is known about the relationship between abnormal movement function and the observed psychosocial deficits. In the present study, 40 clinical high-risk participants meeting criteria for a prodromal syndrome were assessed for movement abnormalities and global role and social functioning at baseline. Role and social functioning were then followed up after a one-year period. At baseline, the severity of spontaneous movement abnormalities was associated with poor role functioning. Further, when controlling for baseline functioning, movement abnormalities predicted changes in social functioning one-year later, with a trend in the same direction for role functioning. Exploratory analyses also indicated that elevated baseline movement abnormalities distinguished those at-risk participants who eventually converted to psychosis and that this was also the case for poorer baseline global role functioning (at the trend level). Taken together, the results suggest that movement abnormalities are closely associated with deficits in psychosocial functioning. Elucidating the link between these phenomena may serve to refine etiological models of frontal-subcortical circuit dysfunction and inform understanding of functioning and outcome of these affected youth.

Longitudinal study of the socioeconomic burden of Parkinson's disease in Germany.

OBJECTIVE: To determine the health economic burden on patients with Parkinson's disease (PD) in Germany over a 12-month observation period and provide a comprehensive analysis of cost-driving factors. METHODS AND PATIENTS: Patients with PD (n = 145) were recruited from two clinical departments, two office-based neurologists and 12 GPs. Clinical evaluations were performed at baseline, 3, 6 and 12 months. Disease severity was measured using the Unified Parkinson's Disease Rating Scale (UPDRS). Cost data were assessed based on a patient diary and via personal structured interviews at the respective time-points. Costs were calculated from the societal perspective (2009 euro). Cost-driving factors were identified by multivariate regression analysis. RESULTS: Mean annual costs totalled euro20 095 per patient. Amongst direct costs, the highest expenditures (euro13 158) were for drugs (euro3526) and inpatient care including nursing homes (euro3789). Indirect costs accounted for 34.5% (euro6937) of total costs. Costs of home care provided by family accounted for 20% of direct costs. Cost-driving factors were identified for total costs (UPDRS, fluctuations, dyskinesia and younger age), direct costs (UPDRS, fluctuations), patient expenditures (UPDRS, depression) and drug costs (younger age). CONCLUSION: Parkinson's disease has a chronic course with growing disability and considerable socioeconomic burden. Disease progression leads to an increasing number of patients who require costly institutionalized care. Home care is a major factor influencing patients' families. Healthcare programmes aimed at reducing the burden of PD on society and individuals should consider cost-driving factors of PD.