Brief Communication NEUROLOGICAL SOFT SIGNS AND PSYCHOPATHOLOGY Incidence in Diagnostic Groups* STEPHEN ARNOLD
High incidences of neurological "soft signs" have been reported in minimal brain dysfunction syndrome (3,8,13), emotionally unstable character disorders (10), hysteria (2), heavy polydrug users (6) and consistently so in schizophrenics (7,9, II, 12). In order to pursue these intriguing reports, the authors conducted a study to determine the incidence of soft signs associated with different diagnostic groups. Soft signs were chosen that were known to be associated with particular cerebral lobes dysfunction. By this method, psychiatric patients and control patients could receive arbitrary scores representing the relative degree of dysfunction of each of the cortical lobes. In summary, the results of this study (4) documented the presence of significantly greater impairment in schizophrenic patients than in all other groups. Furthermore, the noted impairments, while present on measures of total cortical functioning, were mostly accounted for by soft signs assigned to the frontal and parietal lobes. This suggested specific lobular rather than diffuse cortical deficits in these patients. The present study attempts to answer crucial questions raised by the previous study. These questions pertain to (a) performance of different groups of psychiatric patients with respect to individual soft signs rather than combined cortical lobe scores, and (b) the potential influence of "Manuscript received November' 1978; revised February 1979. 'Private Practice, Lexington, Kentucky. 'E.A. Edwards, Professor, Department of Psychiatry, University of Kentucky, College of Medicine, Lexington, Kentucky; 40536. Can. J. Psychiatry Vol. 24 (1979)
M.
M.
COX,
LUDWIG,
M.D.' M.D.2
psychotropic drugs on any reported significant findings. Method The selection criteria employed in this study produced five groups of psychiatric patients from consecutive admissions to a University and Veteran's Administration and a State hospital. A control group was selected from the inpatient population of the internal medicine and surgery services of the same University and Veteran's Administration hospital. The criteria for exclusion included incapacitating medical illness, primary neurological diagnosis, and unwillingness to participate. Informed consent was required. A total of 96 patients were studied and divided into six groups. The five psychiatric groups, including schizophrenia, alcoholism, unipolar affective illness, bipolar affective illness and "mixed" (that is, personality disorders, anxiety, and so on), were defined according to a standardized research protocol employing the Feighner diagnostic criteria (4). Details are provided in the earlier study. Table I presents the pertinent sample characteristics and group size. Although occasional patients within diagnostic groups were found to be without medication, the large majority were on psychotropic agents of some kind. The only common psychotropic agents not found in the sample were monoamine oxidase inhibitors and stimulants (amphetamine). The classes of agents prescribed for the patient population within the three days prior to examination included the following: major tranquilizers (phenothiazines, thioxanthenes, butyrophenones, oxoindoles and dibenzoxazepines), tricyclic antidepressants, benzodiazepines, the non-benzodiazepine sedattive hypnotic minor tranquilizers and antiaanxiety drugs, lithium carbonate, and the narcotic analgesics. One of the unfortunate prob668
November, 1979
669
NEUROLOGICAL SOFT SIGNS TABLE
I
SELECTED SAMPLE CHARACTERISTICS
Group
N
Age (XS.D.) (years)
Control Alcohol Unipolar Bipolar Schizophrenic Mixed
20
19 10 II 21 15
37
44 47
37 36 33
10 II II 13 II 9
Left Cerebral* Dominance (percent)
Psychotropic Medications
95 95
75
(percent) 53
70
100 91 100 93
91 81
46
*Cerebral dominance was determined by tests for hand, foot and eye performance.
lems inherent in this type of study is that no controls were on major tranquilizers whereas 17 of the 21 schizophrenic patients were. Schizophrenic patients who are not taking neuroleptics are almost as rare in the hospital setting as are nonpsychiatric medically ill patients who are prescribed neuroleptics. As a result, it is difficult to provide strict controls for psychotropic drug effects, especially so when most patients are on combinations of medication.
Procedure
All 96 subjects were administered four batteries of neurological soft signs. Each battery contained a series of soft signs presumably related to either frontal, parietal, temporal or occipital lobe dysfunction. Table II lists the specific neurological soft signs in each battery. A complete description of this battery and protocol may be found in the earlier report (4). The reliability of the standardized protocol was evaluated by having a separate rater independently record responses while raters were examining patients. Ten patients were assessed by this procedure. Inter-rater agreement averaged 100%. The criteria used in scoring the soft signs were purposely lenient so that no equivocal response would be overlooked. Although lenient, the criteria were very specific with respect to the determination of preserice or absence of each soft sign. These responses were also scaled with regard to severity. Results
The incidence of individual soft signs varied among the five psychiatric groups
TABLE
II
Frontal Lobe F, Grasp F 2 Palmomental F, Visual Perseveration and Spoken Commands F. Conceptualization and Follow-Through of Difficult Tasks F~ Mnestic Disturbance Due to Poor Effort or to Perseveration F~ avo Mnestic Disturbance Due to Poor Effort or to Perseveration (average score) Parietal Lobe P, Complex Motor Acts P 2 Imaginary Acts P, Oral Apraxia P, Blunt vs. Sharp Discrimination P~ Simultaneous Bilateral Tactile Extinction P, Two Object Test P 7 Astereognosis Temporal Lobe T, Memory T 2 Optokinetic Nystagmus T, Draw-a-Face Test T. Failure to Recognize Anomolies T~ Tapping Rhythm Test Reproduction of Oppositional and Correlations Phonemes Occipital Lobe a, Visual Fields O 2 Optic Gnosis 0, Optic Agnosia
and the control group as shown in Table III. The numbers represent the percentage of patients within that group who exhibit the presence of the particular neurological soft sign. Since the data were not normally distributed, nonparametric statistics were
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TABLE III PERCENTAGE OF ABNORMAL SOFT SIGNS 20 Cont.*
Ale.
19
10 Dep.
II M-D
21 Schizo
15 Mixed
F -I 2 3 4 5
0 0 25 35 20
0 5.3 26.3 15.8 47.4
0 0 30 50 60
9.1 0 9.1 63.6 18.0
9.5 47.6 61.9 42.9 57.1
0 13 13 40 26.7
T -I 2 3 4 5 6
85 0 50 25 55 10
89.5 0 78.9 31.6 63.2 15.8
70 0 70 50 70 30
90.9 9.1 54.5 27.3 81.8 18.2
95.2 9.5 66.7 42.9 61.9 19.0
73.3 20 66.7 20 33.3 0
P -I 2 3 4 5 6 7-R 7-L
5 25 5 20 5 20 10 15
15.8 47.4 0 56.6 0 47.4 21.1 15.8
10 60 0 70 30 70 20 0
0 27.2 0 27.2 9.1 45.5 27.2 0
19.0 61.9 4.8 47.6 28.6 71.4 23.8 19.0
0 73.3 0 33.3 6.7 40 0 6.7
0 - I-R
5 5 0 5
0 10.5 0 15.8
20 10 0 40
18.2 0 0 36.4
0 0 0 28.6
6.7 0 0 13.3
I-L 2 3
*Cont. (controls); Ale. (alcoholics); Dep. (unipolar depressives);M-D (bipolar affective illness); Schizo (schizophrenics); Mixed (mixed psychiatric disorders). TABLE IV STATISTICAL SIGNIFICANCE OF THE INCIDENCE OF SOFT SIGNS IN SCHIZOPHRENIC PATIENTS COMPARED TO OTHER GROUPS
F2 F3 Fj Fjav. P2 P6
Control
Alcohol
xxx xx xx xx xx xx
xx
Unipolar
Bipolar
Mixed
xx xx
xx
xx
xxx p