praecox was due to widespread disease of the frontal, motor and temporal cor- tices. Though it did not receive much attention initially, there had been a steady.
Indian J. Psyehiat. (1990), 32(3), 2 2 3 - 2 2 8 NEUROLOGICAL ABNORMALITIES I N SCHIZOPHRENIC P A T I E N T S AND THEIR RELATIVES K. S. SHAJI 1 J . RICHARD 8 ABRAHAM VERGHESE*
SUMMARY Twenty four schizophrenic patients who met DSM-III criteria, 28 of their nonschizophrenic first degree relatives and a group of 28 normal controls who did not have anv personal or family liistory of major psychiatric illness were assessed by the same investigator for the presence of abnormalities on clinical neurological examination. Patients had significantly greater neurological impairment ( p < . 0 0 l ) than the normal control group. Nonschizophrenic first degree relatives of patients also had greater impairment ( p < . 0 5 ) when compared to the matched control group. Significant excess of neurological abnormalities seen in schizophrenic patients and their close relatives suggest that neurological factors are important in the development of schizophrenia. It was also found that thoie who had luwei education had more neurological abnormalities. The implications of these observations are discussed.
Neurological basis for the syndrome now referred to as schizophrenia had been proposed soon after its description. Kraeplin (1919) suggested that dementia praecox was due to widespread disease of the frontal, motor and temporal cortices. T h o u g h it did not receive much attention initially, there h a d been a steady increase in the studies of the neurologic status of schizophrenia in the last 25 years. Compelling evidence for a neurobiological dimension in schizophrenia has accumulated from neuroanatomical, neuroradiological, neurophysiological a n d neuropsychological studies (Gruzelicr, 1985). Patients diagnosed as schizophrenics frequently sltow abnormalities on clinical neurological examination as well. Earlier studies found increase in both ' h a r d ' (localizing) as well as 'soft' (nonlocalizing) neurological, signs in schizophrenic patients (Rochford, 1910; Pollin a n d Stabcnau, 1968; Larsen, 1964; Uertzig & Birch, 1966). Later studies had focussed mainly on neurological soft signs. 1 Lecture in Psychiatry 2 Reader in Biostatistics 3 Profeiior of Psychiatry
These signs are reported in nonschizophrenic psychiatric patients also. T h e use of the term 'soft signs' had been criticised as unsatisfactory and misleading since most of the abnormalities in question a r e elicited by standard items of the clinical examination (Torrcy, 1980; Henricks & Buchanan, 1988). A recent study by Woods e t a ) . (198") reported increased prevalence of neurological abnormalities indicating localized dysfunction of corticospinal tracts, basal ganglia a n d cerebellum in schizophrenic patients when compared to bipolar patients, patients hospitalised for alcohol or d r u g abuse and normal volunteers. Some workers Kinney, lO.'Jfy f>und higher prevalence of neurologic abnormalities i» nonschizopluem'o first relatives of the above patients. They proposed that the neurological signs may be the result of a n etiological process t h a t is familial. These may Ix: the secondary c o n t r i b u t i n g factors rather than the p r i m a r y defect responsible for the disease a n d any Such
Christian Medical College, Vellore—632002.
factor t h a t push individuals above the threshold for clinical expression of schizophrenia will be of major e p i d e m i o logic significance. Implications of these neurological signs are u n c e r t a i n . T h i s may be because of the limitations in our knowledge. This paper describes a study conducted in the D e p a r t m e n t of Psychiatry, Christian Medical College, Vellore w i t h the objective of looking into the neurological abnormalities in schizophrenic patients and their first degree relatives. Material & Method Selection of populations studied : T h e patients sample was selected from the outpatients a t t e n d i n g the follow up clinics in our centre. Clinicians were requested to refer all schizophrenic p a t i ents to the investigators. Patients h a d to meet D S M - I I I criteria (APA-1980) for schizophrenia to be taken u p for the study. Specific exclusion criteria were epilepsy, mental retardation, organic brain disorder of any type, systemic physical disease, alcohol dependence or drug abuse. Patients who received E C T s in the 6 months prior to testing a n d uncooperative patients whose attention a n d concentration were impaired were excluded from the study. 24 patients whose relatives also agreed to p a r t i c i p a t e in the study, were taken u p for study. All of them were on neuroleptics at t h e time of the study. T h e biological parents a n d siblings of these patients were then invited to participate in tin: study. 29 such relatives who agreed to participate formed t h e sample of relatives. T h e normal control g r o u p consisted of 28 subjects without a n y personal or family history of psychiatric illness. T h e y were selected from the attendence and visitors of the inpatients in our centre
StiAJletal. a n d t h e y were m a t c h e d on age, sex and e d u c a t i o n with the group of 28 relatives. Informed consent was obtained from all subjects after explaining t h e study procedures. Assessment of neurological abnormalities : D e m o g r a p h i c a n d clinical d a t a were collected using a proforma designed for the study. A detailed neurological examination was done based on the standard proforma used for routine neurological e x a m i n a t i o n in the D e p a r t m e n t of neurosciences of our institution. A detailed assessment of neurological signs was performed using tests devised b y Cox a n d L u d w i g (1979). I t s i n t e r r a ter reliability h a d been established by original authors. Jose M a t h e w s (1985) assessed its test-retest reliability and interratar reliability a n d was found to be high (0-979 a n d 0.963 respectively). T h e r e are 21 tests a r r a n g e d i n t o four groups on the basis of presumed lobe functions which they represent. The individual tests were easy to administer. Scoring was done as suggested b y Cox and Ludwig. All subjects w e r e assessed by the same investigator. Statistical Analysis : Analysis of variance was done to find out the significant differences in the scores of neurological i m p a i r m e n t (total as well as sub-scores) between t h e three groups of subjects, taking a g e as covar i a t e a n d sex and education as main effects. T h e j o i n t effects (interaction) of variables like sex a n d education with group differences were also studied using the same technique. T h e three groups of subjects were than compared w i t h each other using ' t ' test in order to find out the g r o u p differences in neurological i m p a i r m e n t . The correlation between the scores of neurolc-
N E U R O L O G I C A L ABNORMALITIES I N
S C H I Z O P H R E N I C PATIENTS
neurological impairment (Table II). Education was found to have significant effects on the total score as well as temporal, parietal, and occipital lobo subscores. Variables like age and sex did not have any significant effects on the scores. The joint effects (interaction) of combination of sex and education with neurological scores were not significant except the combination of group and sex for temporal lobe subscore and the combination of group and education for occipital lobe subscore. The three groups of subject were than compared with each other using't'test.
gical impairment of the patients and their relatives was examined using Pearson correlation coefficient. Results Patients, relatives and controls were similar in age, sex and education (Table I). Patients had a mean age of 23.3 years at the onset of their illness and the mean duration of the illness was 4.8 years. Only o.ie patient had family history of schizophrenia. Analysis of variance showed that the three groups of subjects differed significantly on the total score and subscores of
T A B L E I—Sociodemographic characteristics of schizophrenic patients, their nonschizophrenic first degree relatives and normal controls Patients (n=24)
Mean age* Sex* Male
17 (71%) 7 (29%)
21 (75%) 7 (25%)
21 (75%) 7 (25%)
Education More than 10 years
Ten years & below
T A B L E II—Results of analysis of variance of scores of neurological impairment with tht group of the subject, education and sex as main effects and age as co-variate F VALUE AND SIGNIFICANCE Total
Main effects —Group of the subject —Education —Sex Covariate -Age