Extrapyramidal examinations in psychiatry.

Extrapyramidal signs include increased motor tone, changes in the amount and velocity of movement, and involuntary motor activity. They include two groups of signs and related disorders: hypokinetic (similar to Parkinson's disease) and hyperkinetic (similar to Huntington's disease). This article covers some of the neuroscience behind extrapyramidal disorders, the relevance of extrapyramidal signs in the major psychiatric disorders, the major extrapyramidal movement disorders, and how to elicit extrapyramidal signs.

Reflexes in psychiatry.

Psychiatric patients often do not cooperate fully with the neurologic examination. Reflexes virtually bypass patient effort and are difficult to consciously determine. This article reviews muscle stretch (deep tendon) reflexes, and pathological reflexes including the extensor plantar (Babinski) and primitive release reflexes. Topics include findings in common psychiatric and neurologic conditions and methods for eliciting these signs.

Higher cortical functions: attention and vigilance.

The ability to sustain attention over time (vigilance) is a cognitive function that often is impaired in patients with psychiatric disorders. Attention has been found to be disordered in a number of psychiatric conditions, including attention deficit disorder, schizophrenia, antisocial personality disorder, and the impulse control disorders. Less widely known is the finding that attention also is affected in patients suffering from anxiety disorders, posttraumatic stress disorder, mood disorders, and borderline personality disorder.In this article, the significance of attention deficits with regard to the mood disorders, anxiety disorders, posttraumatic stress disorder, and borderline personality disorder, is described.

Psychiatry, neurology, and the role of the cerebellum.

The cerebellum has long been considered quite separate from the neocortex, and accordingly the understanding of its role has been limited. Recent work has revealed that the cerebellum interacts regularly with the forebrain and it is involved in mood and cognition. In this article, the authors discuss an extensive system of neural circuits connecting the prefrontal, temporal, posterior parietal, and limbic cortices with the cerebellum. Language functions of the cerebellum are described, as well as cerebellar syndromes affecting cognition. The roles of the cerebellum in pain perception, attention deficit disorder, autism, dementia, and schizophrenia are discussed. Practical observations and tests to assess cerebellar function in the psychiatrist's office are described.

Gait and its assessment in psychiatry.

Gait reflects all levels of nervous system function. In psychiatry, gait disturbances reflecting cortical and subcortical dysfunction are often seen. Observing spontaneous gait, sometimes augmented by a few brief tests, can be highly informative. The authors briefly review the neuroanatomy of gait, review gait abnormalities seen in psychiatric and neurologic disorders, and describe the assessment of gait.

Cranial Nerves IX, X, XI, and XII.

This article concludes the series on cranial nerves, with review of the final four (IX-XII). To summarize briefly, the most important and common syndrome caused by a disorder of the glossopharyngeal nerve (craniel nerve IX) is glossopharyngeal neuralgia. Also, swallowing function occasionally is compromised in a rare but disabling form of tardive dyskinesia called tardive dystonia, because the upper motor portion of the glossopharyngel nerve projects to the basal ganglia and can be affected by lesions in the basal ganglia. Vagus nerve funtion (craniel nerve X) can be compromised in schizophrenia, bulimia, obesity, and major depression. A cervical lesion to the nerve roots of the spinal accessory nerve (craniel nerve XI) can cause a cervical dystonia, which sometimes is misdiagnosed as a dyskinesia related to neuroleptic use. Finally, unilateral hypoglossal (craniel nerve XII) nerve palsy is one of the most common mononeuropathies caused by brain metastases. Supranuclear lesions of cranial nerve XII are involved in pseudobulbar palsy and ALS, and lower motor neuron lesions of cranial nerve XII can also be present in bulbar palsy and in ALS patients who also have lower motor neuron involvement. This article reviews these and other syndromes related to cranial nerves IX through XII that might be seen by psychiatry.

Cranial Nerve VIII: Hearing and Vestibular Functions.

Cranial nerve VIII brings sound and information about one's position and movement in space into the brain. The auditory and vestibular systems subserve several functions basic to clinical medicine and to psychiatry. This article covers the basics of cranial nerve VIII, hearing and vestibular systems, including common problems with hearing and balance, problems with hearing and balance that tend to be found in psychiatric patients, and some simple assessments of value in clinical practice.

The Trigeminal (V) and Facial (VII) Cranial Nerves: Head and Face Sensation and Movement.

There are close functional and anatomical relationships between cranial nerves V and VII in both their sensory and motor divisions. Sensation on the face is innervated by the trigeminal nerves (V) as are the muscles of mastication, but the muscles of facial expression are innervated mainly by the facial nerve (VII) as is the sensation of taste. This article briefly reviews the anatomy of these cranial nerves, disorders of these nerves that are of particular importance to psychiatry, and some considerations for differential diagnosis.

Cranial Nerve II: Vision.

This article contains a brief review of the anatomy of the visual system, a survey of diseases of the retina, optic nerve and lesions of the optic chiasm, and other visual field defects of special interest to the psychiatrist. It also includes a presentation of the corticothalamic mechanisms, differential diagnosis, and various manifestations of visual illusions, and simple and complex visual hallucinations, as well as the differential diagnoses of these various visual phenomena.

Cranial nerve I: olfaction.

Olfactory (smell) testing is one of the most interesting and revealing individual neurologic tests in psychiatric research. It is also one of the most neglected tests in the clinical practice of psychiatry. There are several diagnostic applications of smell testing in clinical psychiatry. This review covers reasons for the psychiatrist to test olfaction, ways of testing olfaction, and how to interpret test results.

Cranial Nerves III, IV, and VI: Oculomotor Function.

Motor activity affecting the direction of gaze, the position of the eyelids, and the size of the pupils are served by cranial nerves III, IV, and VI. Unusual oculomotor activity is often encountered in psychiatric patients and can be quite informative. Evaluation techniques include casual observation and simple tests that require no equipment in addition to the sophisticated methods used in specialty clinics and research labs. This article reviews pupil size, extraocular movements, nystagmus, lid retraction, lid lag, and ptosis. Beyond screening for diseases and localizing lesions, these tests yield useful information about the individual's higher cortical function, extrapyramidal motor functioning, and toxic/pharmacologic state.

Tests of a symptom checklist to screen for comorbid psychiatric disorders in alcoholism.

In the treatment of substance use disorders, it is advantageous to identify patients with comorbid (nonsubstance) psychiatric disorders because treating comorbid disorders improves outcome. Because accurate psychiatric diagnosis is time-consuming, there is a need for strategies to screen for these comorbid conditions. This study used receiver operating characteristic analysis to investigate a symptom checklist (revised Symptom Checklist 90 [SCL-90-R]) as a screening instrument for comorbid conditions diagnosed using the Structured Clinical Interview for DSM-IV in 171 primarily military personnel with alcohol use disorders. Several approaches to applying receiver operating characteristic analysis to this problem are demonstrated. Although these results require replication in other populations, the SCL-90-R performed well in predicting comorbid conditions, with an area under the curve of 0.88 for current and 0.85 for lifetime comorbid diagnoses. Self-report symptom checklists such as the SCL-90-R may be useful in screening substance rehabilitation patients for more detailed psychiatric assessment and may prove clinically useful in the assessment of alcoholic patients.

The effects of antipsychotic medication on factor and cluster structure of neurologic examination abnormalities in schizophrenia.

This study extends a previous study of the factor structure of the neurologic examination in unmedicated schizophrenia, utilizing cluster analysis and adding a medicated condition. We administered a modified version of the Neurologic Evaluation Scale (NES) on two occasions to 80 patients with schizophrenia or schizoaffective disorder, once while on antipsychotic medications and once while off medication. Data were distilled by combining right- and left-side scores, and by excluding rarely abnormal and unreliable items from the analysis. Principal components analysis yielded an intuitive four-factor solution in the unmedicated condition, but an inscrutable five-factor solution during medication. Cluster analysis revealed three groups: normal, cognitively impaired, and diffusely impaired. These results were also less interpretable with data from the medicated condition. Neurologic performance was better in the medicated than in the unmedicated condition. As is the case with other domains of symptoms and performance in schizophrenia, relationships among neurologic exam variables are altered by the presence of antipsychotic medication.

Confirmatory factor analysis of the Neurological Evaluation Scale in unmedicated schizophrenia.

Factor structure of the Neurological Evaluation Scale (NES) was evaluated in 95 unmedicated patients with schizophrenia using confirmatory factor analysis (CFA). CFA was used to test four competing models that were based on prior empirical work examining the factor structure of the NES, as well as on theoretical considerations. A three-factor solution composed of "repetitive motor," "cognitive-perceptual," and "balance-tandem" factors best accounted for the data. These findings are consistent with prior exploratory studies that have suggested the NES is a multidimensional procedure that assesses diverse neurological domains. The current results contribute to the development of empirical subscales for neurological assessment procedures to be used in psychiatric conditions.

Relationships between cognitive and neurological performance in neuroleptic-naïve psychosis.

The authors explored relationships between neuropsychological performance and neurological exam abnormalities in 86 never-medicated patients with nonorganic psychosis (59 with schizophrenia or schizoaffective disorder) and 51 healthy subjects. Assessments include a reliable subset of the Neurological Evaluation Scale (rNES) and several neuropsychological tests of attention, executive function, memory, and current and premorbid intelligence. Principal components analysis of the rNES yielded two main factors. Of these, CogPer (consisting of more cognitively demanding perceptual tasks) showed stronger relationships than RepMot (consisting of repetitive manual motor tasks) to neuropsychological measures. Customarily, frontal neuropsychological tasks also relate more strongly to CogPer than to RepMot. Approximately one-half of the variability in these cognitive and neurological assessments is shared.

Early treatment-induced improvement of negative symptoms predicts cognitive functioning in treatment-naive first episode schizophrenia: a 2-year followup.

Studying neuroleptic-naive first episode schizophrenia is a strategy for investigating clinical and neuropsychological abnormalities at a very early phase of the disease without confounding influences of illness duration and medication effects. We examined the clinical and neuropsychological time course over 2 years in 32 neuroleptic-naive first episode patients (20 males, 12 females) and 21 healthy individuals with similar sociodemographic characteristics. Early treatment-induced reduction of negative symptoms predicted superior cognitive performance throughout followup in the domains of verbal fluency, attention, and non-verbal learning and memory. There were no associations between psychotic or disorganized symptoms and cognitive variables. These findings suggest an important relationship between treatment efficacy of antipsychotic medication and the longer term course of cognitive deficits in schizophrenia.

Diagnostic specificity and neuroanatomical validity of neurological abnormalities in first-episode psychoses.

OBJECTIVE: Neurological abnormalities are frequently seen in patients with first-episode psychotic disorders but are generally considered to be diagnostically nonspecific, neurologically nonlocalizing, and, hence, "soft." This study examined the neuroanatomical correlates and diagnostic specificity of abnormal findings on the neurological examination in first-episode schizophrenia and other psychotic disorders. METHOD: Neuroleptic-naive patients with schizophrenia (N=90) and with nonschizophrenia psychoses (N=39) and carefully matched healthy subjects (N=93) were compared on total and factor scores for a reliable subset of Neurological Evaluation Scale items. The relationship between neurological examination abnormalities and alterations in the relevant brain structures as assessed by magnetic resonance imaging was examined in a subset of subjects. RESULTS: Factor scores for repetitive motor task abnormalities were higher in both patient groups, relative to the healthy group, and did not distinguish between the patient groups. Factor scores for abnormalities in cognitively demanding and perceptual tasks were markedly higher in the schizophrenia group, relative to both comparison groups, and were not different between the nonschizophrenia psychoses group and the healthy comparison group. Higher scores for the cognitive/perceptual abnormalities factor were correlated with smaller volumes of the left heteromodal association cortex. CONCLUSIONS: Neurological signs may serve as expedient bedside measures that are potentially useful in the assessment of idiopathic psychoses, and cognitive/perceptual neurological signs may have a measure of diagnostic specificity. These findings provide neurobiological validation of abnormal findings on the neurological examination. These abnormalities may reflect discrete neuroanatomical alterations in schizophrenia and may have a localizing value.

Physical and neurologic examinations in neuropsychiatry.

The direct physical examination of psychiatric patients is underutilized by clinicians and underinvestigated by researchers. Both clinicians and researchers thus bypass important information. The authors review the literature on physical and neurologic examinations, with attention to aspects of these examinations that might specifically enhance the understanding of the psychiatric patient. Coverage includes the "minor" physical anomalies and "soft" neurologic signs. Findings related to the psychiatric conditions themselves are given precedence over findings of general medical importance. Some of the available physical and neurologic examination schedules are reviewed. A unified examination protocol is presented, incorporating physical and neurologic examinations pertinent to both general medical and specifically psychiatric assessment.

Sensory-perceptual dysfunction in patients with schizophrenia and comorbid alcoholism.

We studied the effects of aging and comorbid alcoholism on sensory-perceptual dysfunction in patients with schizophrenia. Using sensory-perceptual tests from the Halstead-Reitan Neuropsychological Battery included in the Russell, Neuringer, and Goldstein (1970) Perceptual Disorders Index, samples were compared of 54 patients with comorbid schizophrenia and alcoholism, 234 patients with schizophrenia but no history of alcoholism, 132 patients with chronic alcoholism and 171 patient controls. Data were analyzed by one-way analyses of variance followed by Scheffe multiple comparison tests. Numerous significant differences were found among groups, with the comorbid schizophrenia group doing more poorly than the other groups on measures of touch perception and suppression, finger agnosia, and fingertip number writing. Multiple regression analyses using the sensory-perceptual tests as predictor variables and age as the dependent variable indicated that the strength of association between age and the multivariate set of sensory-perceptual test scores was greater in the comorbid schizophrenia group than the noncomorbid schizophrenia, alcoholism and patient control groups. The preponderance of age-related deficits was left-sided, suggesting accelerated decline in right hemispheric function. A comparison of groups across ages on a single Perceptual Disorders Index score showed a substantially larger age effect in the comorbid schizophrenia group relative to the other groups.