NEUROLOGICAL SOFT SIGNS IN PSYCHIATRY !!

Neurological soft sign

1. NEUROLOGICAL SOFT SIGNS

2. Neurological signs Hard signs Soft signs Reflect impairment in motor, sensory and reflex function which are localizable Neither localized to a specific area of the brain nor characteristic of any specific neurological condition

3. NEUROLOGICAL SOFT SIGNS Non normative performance on a neurological examination of motor and sensory functioning in the absence of focal lesion. The age upto which this signs are expected to be absent or are considered to be pathological has not been established but decline in these signs on subsequent neurological examination indicate progressive maturity of nervous system.

4. They are associated with deviant brain development like neuronal maturity and neuronal and neuronal integration. Evidence also support by demonstration of association with obstetric complications. Are found in relatives of patient and within families and follow transmission of genetic risk . NSS suggested as markers of disease vulnerability i.e. present prior to the start of the treatment and are independent of illness state.

5. The persistence of NSS into later childhood and adolescence is linked with an increased risk of psychiatric disorders schizophrenia , OCD, ADHD & other neurodevelopemental disorders of childhood.

6. NEURODEVELOPMENTAL MODEL OF NEUROLOGICAL SOFT SIGNS (NSS) . According to this model minor neurological impairments may be viewed as potential signs of deviant brain development and might represent trait markers of vulnerability for neurodevelopmental disorders

7. HISTORICAL PERSPECTIVES Neurological abnormalities were part of early descriptions of schizophrenia phenotype , formally known as ‘ dementia praecox” according to Emil Kraepelin (1919) The term soft neurological signs emerge from the inability of clinicians in the early days to locate the neurpathological bases and clinical relevance of some clinically evident neurological abnormalities. Relevance of NSS started to emerge in the identification of biological markers of vulnerability to neuropsychiatric disorders using advance brain imaging , blood and CSF examination.

8. Rathod B, Kaur A, Basavanagowda D M, et al. (October 19, 2020) Neurological Soft Signs and Brain Abnormalities in Schizophrenia: A Literature Review. Cureus 12(10): e11050. doi:10.7759/cureus.11050

9. SENSORY INTEGRATION Reflect a possible parietal lobe dysfunction and includes reduced ability to perform neurological examination test . Extinction Graphesthesia Asterognosis Right/lest confusion Impaired audio visual integration

10. MOTOR COORDINATION Reflects dysfunction of cerebellum Tandem walking Finger nose test Finger to thumb opposition Diadochokinesia Heal to shin test

11. MOTOR SEQUENCING Reflects abnormalities in connections between basal ganglia and frontal lobe. fist ring ring Fist edge and palm Ozerestskis sign Go/no go test Rhythm tapping (foot or hand b/l )

12. PRIMITIVE REFLEXES Result from abnormalities in frontal lobe Glabellar tap Palmo - mental reflex Pout/snout reflex Sucking/oral reflex Grasp reflex Forced grasping

13. SCALES FOR NSS Neurological evaluation scale (NES) The quantifies neurological scale Heidelberg scale Cambridge neurological inventory Condensed neurological examination Brief motor scale

14. NSS & SCHIZOPHRENIA NSS prevalence in schizophrenia = 50% It is an indictor of both trait (genetic liability ) and state ( acuity of disease process) NSS is much more common in patient with childhood onset and adolescent onset schizophrenia . Evidence supports that “ motor co-ordination” meets criteria to be a vulnerability marker of schizophrenia.

15. TWO -HIT HYPOTHESIS OF SCHIZOPHRENIA

16. This model suggests that schizophrenia is the final behavioural consequence of neurodevelopmental disturbances that start long before the onset of behavioural /clinical symptoms.

17. Endophenotypes are a subtype of biological markers that are expressed along the path from the genotype to the phenotype and are believed to be involved in the pathological mechanisms of a disorder. characterized by the following specific criteria: 1) association with a disease 2) heritability 3) ‘state‐independence’, i.e. being present regardless of illness phase 4) co‐segregation with the illness 5) presence in unaffected relatives of patients at a higher degree than in the general population Endophenotypes can be anything – biochemical, endocrinological , neurophysiological , neuroanatomical or neuropsychological marker, Endophenotypes

18. Neurocognitive endophenotypes in schizophrenia Neurocognitive dysfunction is a hallmark of SZ. Studies have identified attention, working memory and verbal declarative memory as candidate endophenotypes

19. 1. Attention deficits SCZ patients unable to sustain focused attention Can be tested by serial 100-7 test. 2. Working memory (WM) dysfunction Ability to retain short‐term, goal‐oriented information needed for the execution of a specific task Letter number sequence task(LNS) Unaffected first‐degree relatives (FDRs) tend to perform better than SCZ probands , but significantly worse than the healthy population

20. 3. Verbal declarative memory (VDM) deficits   subtype of long‐term memory that reflects the ability to recollect events occurred to the subject (episodic memory), or facts learnt by the subject (semantic memory). VDM deficits present, to a lesser degree, in unaffected FDRs of SCZ probands as well as in subjects at high risk for developing psychosis.

21. Neurocognitive endophenotypes on OCD 5 endophenotypes have been identified motor inhibition : go/no go test cognitive flexibility / set shifting : wisconsin card sorting test planning (and goal-directed behaviour ); tests subjects’ ability to select the correct sub-goal by anticipating the consequence of one course of action on another. working memory error monitoring

22. Neurophysiological endophenotypes Neurophysiological parameters closely reflect the activity of underlying neuronal circuits, thus representing ideal biomarkers for psychiatric disorders Neurophysiological endophenotypes measured during wakefulness are Pre‐Pulse Inhibition Oculomotor anti‐saccades Mismatch negativity P300.

23.  startle response is a reflex behaviorally expressed as the contraction of certain muscles in response to the presentation of an intense and unexpected stimulus The magnitude of PPI and startle response is usually assessed in humans by registering the electromyographic respons e of the orbicularis oculi muscle  its intensity changes under different circumstances, such as, for example, habituation induced by repeated presentations of the startle-inducing stimulus or pre-pulse inhibition  It is significantly less attenuated by exposure to a pre‐pulse in patients affected by SCZ , obsessive‐compulsive disorder, attention deficit disorder, and Huntington's disease PRE PULSE INHIBITION

24. The P300 is a positive evoked EEG potential recorded about 300ms after a deviant, infrequent stimulus is presented , while the subject focuses attention. In SCZ, and both a reduced amplitude and an increased latency of the P300 have been reported P 300

25. NSS & COGNITIVE DISORDERS NSS are frequently found in older persons with Alzheimer's disease but not in those with mild cognitive impairment or normal control. Severity of NSS also increased with the severity of Alzheimer's disease

26. NSS & OCDc Studies showed NSS in the areas of motor coordination and sensory integration , and their presence may be associated with more severe obsessions.

27. NSS IN CHILDHOOD NEURO –DEVELOPEMENTAL DISORDERS The main NSS found in childhood developmental disorders are : Overflow movements : are mirrored in other part of body and occur at the same time as in the part intended to perform the movement . Indicator of delayed development of motor inhibition. Involuntary Movements (IM) : represented by limb tremor, odd posturing, and choreiform movements

28. Dysrhythmia : is an abnormality in an otherwise normal pattern of movements; it can be seen as an improper rhythm or timing of the movement Indicate functional deficits in cerebellum and basal ganglia . Intention tremor : produced by goal-directed motor movements, involves increased rhythmic oscillation at a right angle to the line of movement as the target is approached Dysmetria : the failure to focus the trajectory of an intentional movement

29. SCALES Neurological Examination for Subtle Signs (NESS) Neurological soft signs(NSS) Physical and Neurological Examination for Soft Signs (PNESS)

30. NSS & ADHD In ADHD there are multiple abnormalities in motor system. Studies have found the presence of “ overflow movement “ the maximum. Overflow movement are present before the onset of clinical symptoms and persist in patients with ADHD. Overflow movements Impaired timing of motor response Fine motor deficits

31. NSS & ASD Autism is associated not only with difficulty performing skilled movement but also in understanding these movements. Motor in-co-ordination Difficulty sequencing motor task Sensory disintegration 90% cases

32. Ojagbemi , Akin. (2017). Neurological Soft Signs. 10.1007/978-3-319-28099-8_782-1. D'Agati E, Pitzianti M, Curatolo P, Pasini A. Scientific Evidence for the Evaluation of Neurological Soft Signs as Atypical Neurodevelopment Markers in Childhood Neuropsychiatric Disorders. J Psychiatr Pract . 2018 Jul;24(4):230-238. doi : 10.1097/PRA.0000000000000312. PMID: 30427806. Bombin I, Arango C, Buchanan RW. Significance and meaning of neurological signs in schizophrenia: two decades later. Schizophr Bull. 2005 Oct;31(4):962-77. doi : 10.1093/ schbul /sbi028. Epub 2005 Jun 15. PMID: 15958818. Rabih Fares, Chadia Haddad, Hala Sacre , Souheil Hallit , Georges Haddad, Pascale Salameh & Benjamin Calvet . (2023)  Neurological soft signs and cognition among inpatients with schizophrenia .  Cognitive Neuropsychiatry  28:6, pages 406-423 REFRENCES

33. 5. Rathod B, Kaur A, Basavanagowda D M, et al. (October 19, 2020) Neurological Soft Signs and Brain Abnormalities in Schizophrenia: A Literature Review. Cureus 12(10): e11050. doi:10.7759/cureus.11050 6. Malviya , Juhi & Gawande , Sushil & Faye, Abhijeet & Kirpekar , Vivek & Bhave , Sudhir & Tadke , Rahul . (2022). Neurological soft signs in autism spectrum disorder. Panacea Journal of Medical Sciences. 12. 57-60. 10.18231/j.pjms.2022.011. 7. Matilde M. Vaghi ; (2021).  Neurocognitive Endophenotypes of OCD . The Neurobiology and Treatment of OCD: Accelerating ProgressCurrent Topics in Behavioral Neurosciences, (), –.  doi:10.1007/7854_2020_197 

34. THANK YOU