Correlation of neurological soft signs and negative symptoms in chronic schizophrenic patients

Vol 5, No 1, January - March 1996 _{Chronic Schizophrenia 49}

Correlation

of Neurological Soft

Signs

and Negative

Symptoms

in

Chronic

Schizophrenic Patients

Sylvia

Detri Elvira,* Rudy

Salan"*

Abstrak

Neurological SoTt Srgræ (NSS) banyak diju.npai pada pasien-pasien skizofretria yang kronis dibandingkan dengan yang akut. Gejala negatif, telah

lana

diketahui nrerupakan sekwnpulan gejala yang juga lebih banyak dijunpai pada pasien-pasien skizofrenia kronis. Keduakclonrpokgejalatersebut, dalanr dua dekade terakhir ini, diketahui sebagai gejala-gejala),ang ilrcncer,,tinkan terdapatnl,a kelainan organik pada otak. Tuiuan penelitian

ini

ialah nengeîahui hubungan antara kcdua kelotupok gejala tersebut pada pasietr skizofrenia kronis, khususnya di ru.nah sakit Dr. Cipto Mangunkusurtro dan Runah Sakit JiwaJakarra, rcntpat penelitian ini dilaksanakan (Desenber 1991 hinggaApril 1992). Padapenelitian ini dilakukan peneriksaan klinikpsikiatrik, peneriksaan skor gejala negatifdengan nenggunakan instrwnen SANS dan peneriksaan neurologik unruk NSS terhadap

2I

prtsien skizofrenia kronis sebagai kasus dan

2I

pasien skizofrenia akut (skizofrenifortn) sebagai kelola. Sepuluh orang pasien skizofrenia kronis diperiksa oleh interrater unruk skor SANS dan

1l

pasien skizofrenia kronik lainnl,a untuk penteriksaan NSS. Ternyata didapatkan bahwa pada pasien skizofrenia kronis (teruta,na yang lebih

dari

1O tahun), terdapat hubungan yang bennakna antara NSS dan gejala negatif (0.87). Dari penelitian ini diperoleh pula bahwa NSS _{lebih sering dijuntpai pada pasien skizofrenia kronis daripada skizofrenifonn; dengan denikian bila NSS} dijutnpai pada pasien skizofreniform dan skornya cukup tittggi, dapat nerupakan petwluk prediktif bahv,a pasien tersebut ternasuk ),ang cenderutrg

nerjadi

kronis (Tipe

II

- Crow).

Abstract

Neurological soft sigtrs (NSS) are iltore cont,trotlll'found in chronic schiToprenic patients than in the acute _D'pe ofschizophrenics (schizophrenifonn). The sanre is true

for

negative s)',,tptot,ts, as a s1'ndrone, which is uore _{frequentll.found} in chronic schizophrenic Palients. During the last two decades, these s1'tttptons, had been used as indicatorsfor organic defects in the hunnn brain. The purpose

of

this study is to evaluate the correlation between rhese rwo groups

of

syuptons

in

chronic schizophrenic patienrs ar.

Dr.

Cipro MangunkusutttoGeneral Hospital and The Jakarta State Mental Hospital, where this stud1, w,a-s done. A clinical psychiatric exauinatio^ was done on 2

I

chronic schiTophrenics tts cases and 2

l

schizophreniforn patients as controls (asse.sslrenf _{of negative $.,nptot,ts} rças also done with SANS). AII cases and controls were etanûned

fron

Decentber 1991 -

April

1992, b1, ''*-o indepetrlent int,estigarors. The

rtr$

investiSator did a clinical ps1'chiatric evaluation and did also NSS clinical evaluatiott. The second investigator exa,uined the negative s),tilptotns wirft S,4NS. Ten cases were etanined

for

interrater reliabiliq, of SANS and another I

I

cases.for interrater reliabiliry o/NSS. Fronr this study, we conclude

tlnt

in chronic schizophrenic patients (particularll' those v,ho suffered

for

,,nre than IO years) there were sigttificant cofielatiotts

of

NSS and the negative sy,nptot,ts (0.57).

ht

this report, NSS could be sigttif canrly _found tnore _{frequent in} chronic schizophrenics than in the schizophrenifonn patients. This neans that if the NSS score in schizophrettiforn

patieit

ii

nign,

it

,,ta)1 sen'e as an indicator that the schizophreniforil, na)' develop ittto the chronic q,pe (Second Type - Crow).

Keywords

:

NSS, negative s)',,tpton6, SANS, chronic schizophrenic

INTRODUCTION

Theories

of

etiology

and pathogenesis

of

schizo-phrenia, have

been

attributed

to

brain

dysfunctions.

In

recent

years,

psychiatric attention

to

the

neuro-*

_{Departnent of Psychiatry,, Facultl, of Medicine, IJttiversir.y.}

of Indonesia, Jakarta, Indonesia

**

_{The National Ltstitutefor Health Research and} Develop-tilent, Ministry of Health R.1., Jakarta, Indonesia

pathology

or

neurodysfunctional

in

schizophrenic

patients has increased. These, are

related

to

new

find-ings in neuroradiology

and

neurophysiology.

50

ElviraandSalan

Among

various abnormalities, neurological

signs,

either 'hard' or

'soft',

were

shown

by

some studies

to have

a

higher

frequency

in

schizophrenics

than

normals.r

'Hard'

signs, have predictive localizing

power, usually referrable

to

specific

lesions

of

nuclei,

tracts, and

nerves.

'Soft'

signs, represent abnormal

performance

on

less

specific

tests,

none

of

which

by

themselves

indicate

a

clearly

identifiable

central

nervous system

lesion. Neurological soft

signs

(NSS),

according

to many

researchers,

can

be

used

as

in-dicators

6f

tron

specific

damages

of

human

brain.2

NSS are more commonly

found

in

schizophrenic

patients than other

psychiatric

disorders

and

normal

control,2'3'a'5

und

u#ong

the

schizophrenics,

NSS are more

frequent

in

the

chronic

patients rather than

in

the

""rrt".".à".1'6

Some studies have shown

a

significant

correlation

ive

symptoms

in

chronic

and also in

relation

with

the

u.6'8

Cro*

et

al

(1980)

sugessted the use

of positive

and

negative symptoms

as a

postulate

of

two

types

schizophrenia.

The

first

type

of

schizophrenics shows acute onset

of

illness,

normal intellectual functions, normal brain

structure,

good

reponses

to

antipsychotics and the

absence

of

negative symptoms.

The

second

type,

is

schizo-phrenics

who have an insidious onset

of

illness,

a

decrease

in

intellectual functioning, widening

of

lateral ventricles

of

the brain,

poor

responses

to

anti-psychotic medication, and the

presence

of

negative

.y.ptorn..e'10'll

In

almost

uil

of

schizophienic

patients, the positive symptoms are usually

present

during

the process

ofillness, however,

the occurance

of

negative symptoms

are

key

factors

in

the

advance stage

of

clinical

signs. Usually

the negative

symptoms

are

prominent

in

the

late

stage

of

the

illness.

Once

the

negative symptoms are

found,

this may

become

permanent and schizophrenic

process

may

develop

into

schizophreniaof

second

type, which

will

prone

to

be

irreversib

le.t2't3'14

In

chronic schizophrenic patients, there are

neuro-physiological

dysfunctions,

and a

variety of structural

defects

of

the

brain may

occur.

The main

defects

were

thought

to

be

in

the frontal

lobe and

lymbic

sys-tem. f2' I s

Clinically

the

chronic

schi zophrenic patients, are

proggressively

deteriorating.

It

may be possible

that the presence and increase

of

NSS is

concommitant

with

the

process

of

deterioration.

The

same process

may

also

occur

with

the

negative symptoms.

The main purpose

of

this

study

is

to

measure

the

correlation

between NSS and negative symptoms,

in

Med J Indones

chronic schizophrenic

patients.

The

first

hypothesis

: there is a

significant

correlatiorr of negative symptoms

and NSS

in

chronic schizophrenic

patients.

The

second

hypothesis

:

NSS are

significantly

more

fre-quent

in

chronic

schizophrenic patients compared

to the acute

type

of

schizophrenics (schizophreniform).

MATERIAL

AND

METHODS

Twenty-one chronic schizophrenic patients

(12 men, 9

women) were

comparatively

evaluated

with

2l

schizophreniform patients

(10

men,l

I

women

)

at the

Psychiatric

Clinic

of

the

Department

of

Psychiatry,

Dr.Cipto

Mangunkusumo General

Hospital

and

The

Jakarta State

Mental

Hospital

during the period

of

December

1991

until

April

1992.

The study

consisted

of

three

steps. The

first

was

a

clinical

psychiatric examination, to

establish the

diag-nosis

of

schizophrenia using the criteria

based

on

Pedonran

Penggolongan dan Diagnosis

Gangguan

Jiwa

di Indonesia

edisi

II

(PPDGJ-II),r6 which

con-firms with

the

criteria

of The

Diagnostic

and

Statistical

Classification for Mental Disorders (DSM)

III-R.

In-clusion criteria

for

the subjects and

controls were

: (l)

schizophrenic patients

who

had been

ill

for

ten

years or more

for

the subject group, and/or

who

were

in their

first

episode

of their

illness

for

less than 6 months

for

the control group;

(2)

free

from

systemic

physical

illness;

(3)

no

history of

severe

CNS (central

nervous

system)

disorder

and substance abuse;

(4)

no

history

of

electroconvulsive therapy (ECT) and

(5)

no

sig-nificant

side-effects

from

neuroleptic medication.

The second step consisted

of

the

identification

of

NSS and negative

symptoms which

were done

by two

inde-pendent

investigators. The

first

investigator examined

the scores

of

NSS, and the second

investigator

scored the

negative symptoms

by

using SANS (the

Scale

for

the Assessment

of

Negative Symptoms) instrument.lT

The

third

step measured

interrater

reliability

between the

investigator

and

a

neurologist

by

simultaneous-ly

and

independently

rated

the

NSS'scores

(ll

subjects).

Interrater

reliability

for

SANS

was done on ten subjects

by two psychiatrists.

The sample size

was

established

by

using the Fleiss'

Vol 5, No 1, January - March 1996

The Spearman's

rank correlation coefficient

test

was used

to correlate

NSS and

negative symptoms. A

one

tailed Mann-V/hitney u

test

was applied

to

compare

NSS scores

of

chronic schizophrenics and

schizo-phreniform

patients. le

RESULTS

The Spearman's

rank

correlation coefficient

test

between

NSS and

negative

symptoms

in

chronic

schizophrenic

patients is

found

to

be significant.

It

may be concluded that the

first

hypothesis

is accepted.

The use

of

the one tailed Mann-Whitney

u

test

to compare the NSS

in chronic schizophrenic

patients

to the acute

type (schizophreniform)

is also significant

( p =

.O0O

). It

complies

with

the

earlier studies

that

NSS

are

significantly

more frequent

in

chronic

schizophrenic

patients

than in

the

acute type

(schizophreniform).

Table

1.

NSS

&

SANS total score and demographic charac-teristic ofthe patients and controls

Chronic schizophrenic

(n=

2I)

mean

Schizophreniform

(n=21)

mean

ChronicSchizophrenia

5l

DISCUSSION

The significant

result

of

the study on the correlation

between

NSS and negative

symptoms

in

chronic

schizophrenic supports the previous studies by

Hein-richs

et

al,'

Bartko

et

al.l9880

and Rossi et al.

/

It

was

also found that NSS

are

manifested more frequent in

chronic

schizophrenic

patients compared

to

schizo-phreniform. This confirms

with

the

previous

studies

of

Heinrichs

and

Buchananl

and

Woods

et a1.20

It

was

previously

suggested

that

the presenc€

of

NSS

and negative symptoms

may reflect

the existence

of

non specific brain damages. However,

it

should

be

confirmed

by other

diagnostic

procedures such as

com-puted

tomography scan, magnetic

_resonance

imaging,

positron emission tomography,

etc.

The

present

of a

high

score

of

NSS

in

schizo-phreniform patients

may

serve as a

predictor

that the

schizophreniform type may develop

into the chronic

type

( the second

type of Crow's schizophrenia).

CONCLUSIONS

The results

of

this study

confirm the significant

cor-relation

between NSS and negative symptoms in

chronic schizophrenic

patients.

NSS are

significantly

more frequent

in chronic schizophrenics compared

to

schizophreniform

patients.

These

findings

may

sup-port

the prognostic values

of

both NSS and negative

symptoms

in

the evaluation

of

schizophrenic

condi-tion.

Acknowledgement

We

are

indebted to dr.

Sasanto

Wibisono for his

sug-gestions

on this

paper.

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&.95

38.19

10.66

0.86 20.47 25.61

10.90

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of

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%,

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schizophrenics 42.85% ( table

_{2 ).}

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Clinical Diagnosis of Cfuonic Schizophrenic patients

Diagnosis

female

male

sum

Schiz. Paranoid Schiz. Hebepfuenic Schiz. Residual Schiz. Undifferentiated Sum

2 2 4

1

9

68

l3

59

0l

12

2t

[image:3.595.37.270.374.481.2] [image:3.595.35.267.652.742.2]

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