Abnormal Involuntary Movements

In recent years, there have been systematic attempts to characterize abnormal involuntary movements presumed to be intrinsic to schizophrenia. Kraepelin observed that some patients with psychosis had fixed facial expression and slow shuffling movements reminiscent of Parkinson's disease (Crow et al. 1982, 1983) and described features in dementia praecox indistinguishable from contemporary accounts of TD.

Whereas Kahlbaum conceptualized catatonia as a brain disorder, Bleuler believed that all motor symptoms of schizophrenia were in some way related to the psychic factors (Arieti 1972); however, following the epidemic of influenza in the second decade of the twentieth century, which resulted in large numbers of cases of encephalitis lethargica, there was further discourse on the possibility that psychotic symptoms seen in psychiatric disorders and motor dysfunction both arose from abnormal brain function (Dretler 1935; Steck 1926/1927).

When TD was initially described in the 1950s, there was considerable debate about the origins of these movements. For example, some authors suggested that these were stereotypic, whereas others described them as choreiform (Degwitz 1969; Fahn 1983; Klawans 1983). Indeed, there was much discussion about what constituted mannerisms, stereotypies, dyski-netic movements, dystonia, and the parkinsonian symptoms of tremor and rigidity (Rogers 1985). Pertinent to these discussions, Rogers (1985) reported on a population of outpatients who had received a diagnosis of severe psychiatric illness (the majority of them with schizophrenia) and who were initially hospitalized before the introduction of neuroleptic medications (1907-1955). In the process of reviewing their charts, Rogers noted that although these patients were not selected by diagnosis, nearly all met the current criteria for a diagnosis of schizophrenia. In this neuroleptic-na'ive population, abnormalities of virtually every aspect of motor function were described (see Table 10-2).

Table 10-2. Comparison of movement disorders among hospitalized schizophrenic patients and those with mental handicaps in the pre-antipsychotic era

Schizophrenia group (%)

Whole group 1907-1926

1927-1935

1936-1955

Mental handicap

Table 10-2. Comparison of movement disorders among hospitalized schizophrenic patients and those with mental handicaps in the pre-antipsychotic era

Schizophrenia group (%)

Whole group 1907-1926

1927-1935

1936-1955

Mental handicap

Motor disorder

(n=100)

(n=34)

(n=33)

(n=33)

group (n=99) (%)

Speech production

92

94

97

88

85

Activity

84

88

94

70

39

Purposive movement

83

85

79

85

97

Facial movements or postures

77

85

67

79

52

Head, trunk, or limb movements

71

62

76

76

32

Posture

50

50

45

56

62

Eye movements

28

29

24

30

25

Tone

14

21

6

15

54

Gait

10

15

12

3

71

Blinking

5

3

0

12

12

Source. Adapted from Rogers (1985, 1991).

3 fD

Table 10-3. Association of current motor disorder with neuroleptic medication status

Medication statusa (%)

Table 10-3. Association of current motor disorder with neuroleptic medication status

Medication statusa (%)

Motor disorder

Whole group (n=100)

A (n=43)

B (n = 12)

C(n=12)

D (n=12)

E (n = 13)

F (n=8)

Purposive movement

97

100

92

92

100

100

88

Speech production

95

98

92

100

83

100

88

Posture

86

88

83

92

67

100

75

Tone

85

93

92

58

75

100

75

Facial movements or postures

74

81

83

58

75

62

63

Head, trunk, or limb movements

67

67

75

83

58

69

38

Activity

64

74

67

67

50

46

50

Stride or associated movements

48

49

42

25

50

62

63

Eye movements

48

50

17

58

42

46

50

Blinking

38

39

67

33

42

23

38

aGroup A: currently receiving neuroleptic medication Group B: no medication for 1 month Group C: no medication for 1 year Group D: no medication for 5 years Group E: no medication for 15 years Group F: never medicated n> c o

Ol t

ii 3

aGroup A: currently receiving neuroleptic medication Group B: no medication for 1 month Group C: no medication for 1 year Group D: no medication for 5 years Group E: no medication for 15 years Group F: never medicated

Source. Adapted from Rogers (1985).

For these patients, motor dysfunction was as prominent a part of their illness as were their psychotic symptoms and functional disability. Rogers himself conceded that attempting to sort out what was functional and related to psychosis versus what was a neurological manifestation became superfluous if severe psychiatric disorders themselves were viewed as neurological conditions.

The introduction of antipsychotic or neuroleptic medications in the 1950s shifted the focus of attention from the existing motor dysfunction to neuroleptic-induced extrapyramidal signs and symptoms (Manschreck 1986). Chlorpromazine, the first neuroleptic to be widely used, appeared to worsen motor function. In this regard, the term neuroleptic actually refers to a substance that produces symptoms resembling those of diseases of the nervous system (Taber's 1981). Specifically, the reference was to Parkinson's disease. Table 10-3 indicates the percentages of patients in the sample Rogers studied who had motor disorders in relation to neuroleptic medications (Rogers 1985). Although those patients who were on active medication had a tendency toward greater prevalence of motor abnormalities, these abnormalities are still seen with high frequency among the never-medicated patients with schizophrenia.

As part of resurgent interest in the evaluation of patients with a first episode of schizophrenia or related psychotic disorder, various aspects of motor dysfunction have been studied prior to any treatment with antipsy-chotic medication (Browne et al. 2000). In part, this is related to the fact that motor abnormalities clearly predate exposure to neuroleptic medication. Furthermore, it may be possible to correct or ameliorate some aspects of abnormal motor function if patients are treated with one of the newer, second-generation or atypical, antipsychotic medications (Kopala et al. 1998; Whitehorn and Kopala in submission).

Extrapyramidal signs and symptoms are sometimes divided into categories, which include parkinsonism, dystonia, dyskinesia, and akathisia. These signs and the most commonly used clinical and research rating scales are outlined next.

1. Parkinsonism: Bradykinesia (difficulty initiating movements), rigidity, abnormal gait and posture, tremor, sialorrhea, postural instability, diminished expressive automatic movements, masked facies, low monotonic speech. Rating scales: Simpson-Angus Scale (SAS; Simpson and Angus 1970), Extrapyramidal Symptom Rating Scale (ESRS).

2. Dystonia: Sustained increase in muscle tone resulting in abnormal posture. Rating scales: SAS, ESRS.

3. Dyskinesia: Involuntary movements in any muscle groups. Rating scales: Abnormal Involuntary Movement Scale (AIMS), ESRS.

4. Akathisia: Objective observation of inability to remain still, subjective experience of restlessness and dysphoria. Rating scale: Barnes Akathisia Scale (BAS; Barnes 1989).

In reviewing the first-episode data, it becomes clear that a variety of different rating scales have been used to quantify these abnormalities, and that some studies include a heterogeneous sample of young individuals who have been ill for relatively short periods of time and more chronically ill subjects, some of whom were never treated (Fenton 2000). Thus, as can be seen from Table 10-4, there was considerable variability in these studies in the prevalence of parkinsonism, dystonia, and dyskinesia, which may well be related to the heterogeneity and small sample sizes. Nonetheless, it is worth noting that with specific reference to parkinsonian signs, tremor was relatively rare compared with bradykinesia and rigidity.

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