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Dyskinetic movement disorder among adults with mental retardation: phenomenology and co-occurrence with stereotypy.

We screened for the occurrence of dyskinetic and stereotypic movement disorders using item-independent screening protocols to determine whether these forms of movement disorder can be distinguished among adults with mental retardation. Stereotypies and dyskinesias were reliably distinguished in terms of topography. Tardive dyskinesia occurred in 18.2% of a cohort of individuals receiving chronic neuroleptic treatment. Stereotypic movement disorder was associated with increased dyskinesia scores and increased prevalence of tardive dyskinesia. Increased dyskinesia scores were also found for subjects exhibiting stereotypy who had been free of neuroleptic treatment for 3 years. Results indicate that dyskinesia and stereotypy are discriminable movement disorders and provide preliminary support for the hypothesis that they may be related by common mechanisms.

Adolescent↗

Sleep bruxism; an overview of an oromandibular sleep movement disorder. REVIEW ARTICLE.

Sleep bruxism (SB) is a stereotyped movement disorder characterized by grinding or clenching of the teeth during sleep. The majority of the population will at some time during their lifetime grind or clench their teeth. It becomes a pathological condition when the subject presents severe tooth damage or complains of non-restorative sleep. The prevalence of SB is difficult to estimate, since quite often the subjects are unaware of having the disorder. There is no gender difference. SB is more frequent in the younger generation, with a decline over age. The symptom recognized in children can persist in adulthood. The aetio-pathophysiology is still unclear. SB has been associated with tooth interference, psychosocial and environmental factors, brain transmitters and basal ganglia dysfunction. Attempts have been made to specify the personality traits of bruxers, reported to be greater anxiety or vulnerability to stress; however, this is still controversial. SB subjects were observed to present vigilance-sleepiness and somatic problems. However, they are generally good sleepers. Some authors reported SB during all sleep stages, others observed the majority of bruxe episodes during light sleep and REM and often associated with arousal transients. No abnormalities of the autonomic nervous system could be shown in awake SB subjects. While some studies have shown an association between SB and PLM or breathing disorders, others did not confirm this. There is no specific treatment for SB: each subject has to be individually evaluated and treated. Three management alternatives are used: dental, pharmacological and psychobehavioural.

Journal Article↗

Self-mutilation and Tourette's disorder.

Tourette's disorder is a stereotyped movement disorder that carries with it the risk of self-mutilation. Two cases are presented in which children with Tourette's disorder mutilated themselves. Possible physiologic mechanisms by which self-mutilation occurs in patients with Tourette's disorder are reviewed and treatment strategies are discussed.

Adult↗

Autistic-spectrum disorders in Down syndrome: further delineation and distinction from other behavioral abnormalities.

The present study extends our previous work characterizing the behavioral features of autistic-spectrum disorder (ASD) in Down syndrome (DS) using the Aberrant Behavior Checklist (ABC) and Autism Behavior Checklist (AutBehav). We examined which specific behaviors distinguished the behavioral phenotype of DS + ASD from other aberrant behavior disorders in DS, by determining the relative contribution of ABC and AutBehav subscales and items to the diagnosis of ASD. A total of 127 subjects (aged 2-24 years; mean age: 8.4 years; approximately 70% male), comprising: a cohort of 64 children and adolescents with DS and co-morbid ASD (DS + ASD), 19 with DS and stereotypic movement disorder (DS + SMD), 18 with DS and disruptive behaviors (DS + DB), and 26 with DS and no co-morbid behavior disorders (DS + none) were examined using the aforementioned measures of aberrant behavior. We found that subjects with DS + ASD showed the most severe aberrant behavior, especially stereotypy compared to DS + none and lethargy/social withdrawal and relating problems compared to DS + SMD. Specifically, relatively simple stereotypic behavior differentiated DS + ASD from DS + DB, whereas odd/bizarre stereotypic and anxious behavior characterized DS + ASD relative to DS + SMD and DS + none. Additionally, in a subset of subjects with DS + ASD and anxiety, social withdrawal was particularly pronounced. Overall, our findings indicate that a diagnosis of DS + ASD represents a distinctive set of aberrant behaviors marked by characteristic odd/bizarre stereotypic behavior, anxiety, and social withdrawal.

Adolescent↗

The Aberrant Behavior Checklist and the Behavior Problems Inventory: convergent and divergent validity.

This study was designed to compare and cross-validate two rating instruments [the Aberrant Behavior Checklist (ABC) and the Behavior Problems Inventory (BPI)] for assessing maladaptive behavior. The BPI assesses three types of behavior problems: Self-Injurious Behavior (SIB), Stereotyped Behavior and Aggressive/Destructive Behavior. The ABC assesses five domains including these three. We collected data on 226 adults, mostly with severe or profound mental retardation, from a medium-sized developmental center. Individuals with elevated BPI scores generally had higher ABC scores; however, the extent of covariation differed across subscales. Similarly, multiple regression analyses showed that BPI subscales significantly but selectively predicted ABC subscale scores. Measures of differential diagnostic value (positive and negative predictive power, sensitivity, specificity and overall correct diagnostic efficiency) confirmed the anticipated partial overlap between instruments. Both instruments were used to rate participants with and without a Diagnosis of Stereotyped Movement Disorder. BPI, SIB and Stereotypy subscale composite had stronger positive predictive power than the ABC Stereotypy scale, while the ABC had higher negative predictive power and greater overall diagnostic efficiency. Thus, the ABC and the BPI cross-validated one another where expected, and they diverged for subscales thought to have little relationship.

Adaptation, Psychological↗

Electroencephalographic findings in Rett syndrome.

Rett syndrome is a progressive neurologic condition, affecting only girls and characterized by acquired microcephaly, dementia, seizures, autistic behavior, spontaneous hyperventilation, spasticity, hyperreflexia and a peculiar characteristic stereotypic movement disorder. A review of 35 EEGs (obtained over 0-8.5 years of follow-up) in 9 such patients revealed a striking age-related change in the electroencephalographic pattern. Often initially normal, the EEG shows a variety of epileptiform abnormalities but intact background activity between 3 and 5 years. Between 5 and 10 years of age, the background activity exhibits some slowing, epileptiform abnormalities persist and paroxysmal high-amplitude theta activity occurs over extended periods, related to spontaneous hyperventilation. After 10 years, there is a general reduction in the epileptiform activity but further slowing of the background rhythms is usually observed. As all other laboratory tests are mostly normal in Rett syndrome, EEG promises to be a powerful tool in confirming the diagnosis in a compatible setting, in follow-up of these patients, and in objective evaluation of any future therapeutic interventional modalities in this serious and common condition.

Adolescent↗

Cyclic alternating pattern as a provocative factor in nocturnal paroxysmal dystonia.

PURPOSE: We made a polygraphic study of 6 patients with nocturnal paroxysmal dystonia (NPD) in which the cyclic alternating pattern (CAP) parameters were compared with those of a group of age- and sex-matched controls. METHODS: All patients met the requirements for NPD diagnosis, characterized by generalized stereotyped movements (dystonic-dyskinetic), with a 1-min centered duration but with no clear evidence of epileptic abnormalities in the waking EEG and during nocturnal recordings. RESULTS: Besides the major events, the NPD polysomnograms also showed shorter, repeated episodes of shorter duration (generally <20 s) consisting of abrupt movements involving one or more body segments. Overall, the motor events in patients with NPD were closely related to periods of unstable non-REM (NREM) sleep, as evidenced by the sequences of CAP, and began during an A phase. According to the conventional scoring parameters, NPD and controls differed only in sleep latency (+14 min in the NPD patients: p < 0.04). However, the architecture of sleep in the group with NPD was characterized by prolonged and irregular NREM/REM cycles. In addition, the NPD recordings showed significantly higher values of CAP rate (p < 0.0001). When major motor attacks were suppressed by medication, sleep was characterized by a decrease in the excessive amounts of CAP rate and by a more regular architecture. CONCLUSIONS: The modulatory role of CAP on nocturnal motor events is reported.

Adolescent↗

Fluvoxamine for stereotypic behavior in patients with dementia.

OBJECTIVE: To describe the effects of treatment with the selective serotonin reuptake inhibitor fluvoxamine on three patients with advanced dementia who developed a stereotypic movement disorder. CASE SUMMARY: Three patients in a skilled nursing facility were referred by their primary physicians for psychiatric consultation to assist with the management of stereotypic behaviors. The patients received a standard medical, neurologic, and psychiatric workup for dementia. Two of the patients were diagnosed with dementia of the Alzheimer type and the other patient was diagnosed with vascular dementia. All three patients were started on fluvoxamine 25 mg/d; behaviors were monitored daily by the nursing staff and their primary care physicians and weekly by their psychiatrist using the Abnormal Involuntary Movement Scales. The dosage was titrated upward weekly to a maximum dosage of 150 mg/d. RESULTS: Two patients showed complete resolution of their stereotypic behaviors by week 6. The third patient showed noticeable improvement with some residual movements after 8 weeks of treatment. CONCLUSIONS: Fluvoxamine appeared effective in the control of stereotypic behaviors in three patients with advanced dementia.

Aged↗

An A-B-C model of habit disorders: hair-pulling, skin-picking, and other stereotypic conditions.

Severe hair-pulling is characteristic of trichotillomania, an impulse control disorder not otherwise classified. Other pathological habits, including severe nail-biting and skin-picking, are also prevalent and are potentially diagnosable as stereotypic movement disorder. There is increasing awareness of the morbidity associated with these kind of habit disorders but, to date, relatively few randomized controlled trials of pharmacotherapy or psychotherapy have been undertaken. Advances in the understanding of the underlying cognitive-affective mechanisms driving stereotypies in animals and humans may ultimately lead to new approaches. An affect regulation, behavioral addiction, and cognitive control (A-B-C) approach is outlined to conceptualizing and managing these conditions.

Adult↗

Effects of intrastriatal administration of selective dopaminergic ligands on spontaneous stereotypy in mice.

Abnormal repetitive behaviors are often associated with specific developmental, genetic, and neuropsychiatric disorders. Repetitive motor behaviors, often referred to as stereotypies, have been studied extensively as they can be readily induced by certain drugs (e.g., amphetamine). Recent work has shown, however, that such drug-induced models of stereotypy may not accurately reflect the neurobiological perturbations responsible for the spontaneous manifestation of these behaviors. The present study employed the deer mouse model of spontaneous and persistent stereotypy to evaluate the capacity of several selective dopaminergic agonists (apomorphine, SKF81297, and quinpirole) to exacerbate levels of spontaneously emitted stereotypic topographies when administered intrastriatally. Additionally, the effects of intrastriatal administration of the D(2)R antagonist raclopride on the expression of spontaneous stereotypic jumping were evaluated. No induction or exacerbation of stereotypy was observed following administration of the selective D(1)- or D(2)- receptor agonists, and the mixed agonist apomorphine induced hyperlocomotion and excessive grooming but failed to exacerbate spontaneous stereotypy. Thus, a dissociation was observed between spontaneously emitted and drug-induced stereotypy, suggesting significant limitations to the use of dopamine agonist-induced stereotypy as a model of clinical stereotyped movement disorder. Furthermore, an unexpected and statistically significant (P<.05) potentiation of locomotor activity was observed following intrastriatal raclopride administration, suggesting major alterations to the modulatory characteristics of the striatal dopaminergic system in these spontaneously stereotypic animals.

Animals↗

Power-law scaling for macroscopic entropy and microscopic complexity: evidence from human movement and posture.

We investigated the relationship between macroscopic entropy and microscopic complexity of the dynamics of body rocking and sitting still across adults with stereotyped movement disorder and mental retardation (profound and severe) against controls matched for age, height, and weight. This analysis was performed through the examination of center of pressure (COP) motion on the mediolateral (side-to-side) and anteroposterior (fore-aft) dimensions and the entropy of the relative phase between the two dimensions of motion. Intentional body rocking and stereotypical body rocking possessed similar slopes for their respective frequency spectra, but differences were revealed during maintenance of sitting postures. The dynamics of sitting in the control group produced lower spectral slopes and higher complexity (approximate entropy). In the controls, the higher complexity found on each dimension of motion was related to a weaker coupling between dimensions. Information entropy of the relative phase between the two dimensions of COP motion and irregularity (complexity) of their respective motions fitted a power-law function, revealing a relationship between macroscopic entropy and microscopic complexity across both groups and behaviors. This power-law relation affords the postulation that the organization of movement and posture dynamics occurs as a fractal process.

Adult↗

Animal models of obsessive-compulsive disorder: rationale to understanding psychobiology and pharmacology.

Animal models have shown progressive development and have undoubtedly proven their supportive value in OCD research. Thus, various animal models have confirmed the importance of the 5-HT [72-74] and dopamine systems [104,111] in the neurobiology and treatment of OCD. Given the neurochemical, emotional, and cognitive complexity of the disorder, how-ever, animal models are being used to investigate more and more complicated neurochemical and behavioral theories purported to underlie OCD. The lever-press model, for example, has implicated deficient response feed-back in a neural system that regulates operant behavior [74]. Studies on stereotypic movement disorder [89] have opened a new avenue of investigation into the neurobiology of stereotypy that may be applicable to more complex syndromes such as OCD. Models that have focused on specific neuropsychologic aspects of OCD such as reward [74], displacement behavior[63,101], perseveration and indecisiveness [73,102], and spontaneous stereotypy [90,94] are important in their attempt to unify the diverse behavioral manifestations of this disorder. It is clear that for a deeper, more holistic understanding of OCD, multiple animal models will be needed to allow investigation of the various aspects of the disorder and to provide convergent validation of the research findings. The heterogeneous nature of OCD, the various subtypes that exist within the disorder, and the range of obsessive-compulsive spectrum disorders suggest that particular questions regarding OCD may be addressed best by us-ing a particular ethologic model, whereas other questions might require a pharmacologic model or a combination of both for meaningful results[62,115]. Genetic models will be extremely useful for studying the genetics of pathologic behavior and for relating these findings to neuroanatomic and neurochemical changes in the model (eg, DICT-7 mice as a model for Tourette's syndrome and OCD). Neither ethologic nor pharmacologic models, however, can assess whether the "compulsive" behavior is a response to an "obsessive" anxiety or fear. Perhaps the symptoms seen in patients who have OCD, which may be exacerbated by everyday stress, are analogous to displacement behaviors in animals and also reflect some form of anxiety or stress [98]. In this regard, the bank vole model [116]has provided evidence that previously developed stereotypies increase markedly after acute stress and argues that healthy individuals "habituate" to everyday stress, whereas patients who have OCD do not. Interindividual variation in behavioral response and attempts to replicate studies in different laboratories often is the nemesis of the behavioral scientist. Small within- and between-subject variability is usually desirable, how-ever, because there are cases in which the study of the variability of the model could lead to a better understanding of the disorder. Variability can-not always be considered an error; it is possible that previously disregarded neuronal systems may have a place in the observed variation and, indeed, in the pathophysiology of OCD. In this regard, SRIs are not always effective for OCD [6,29,30] such that a lack of effect in a model may reflect an un-known neurobiological basis for compulsive behavior in a sub-group of SRI refractory patients. Similarly, separating the afflicted (ie, working with animals that show greater behavioral change in a model and/or after drug treatment) would have distinct benefits. To increase successful implementation of an ethologic animal model, especially when reinforcement models or signal attenuation models are used,the laboratory must be equipped with the essential behavioral testing apparatus as well as the operant chambers/rooms in which to conduct the train-ing and data collection. Quantification of certain stereotypy behaviors also requires experienced or trained observers. An illustration of the difficulty in measuring behavioral changes is that in the rewarded alternation model,a good response to behavioral treatment (alternation training) may lead to a floor effect [73] which, after successful drug treatment of the animal,produces no residual persistence (ie, measurable behavioral change) on which a drug treatment can be tested. Clearly, the choice of ethologic, pharmacologic, or genetic models should be considered carefully. A well-validated model may quell many of the limitations and considerations described previously. Noninvasive neuroimaging(eg, the use of small-animal single-photon emission CT) to explore the neuroanatomic basis of OCD offers an exciting future challenge, especially if combined with pharmacologic or ethologic models, and could confirm or ex-tend knowledge of the neuroanatomy of OCD. Although studies to investigate further the interactive role of 5-HT, dopamine, GABA, and glutamate are still needed, the role of neuroactive peptides such as cholecystokinin, corticotrophin-releasing factor, neuropeptide Y, tachykinins (ie, substance P),and natriuretic peptides in OCD should also be considered. Genetically engineered animal models will become increasingly valuable in combination with new technologies such as gene-chip microarrays, RNA interference, and advanced proteomics that will help further the understanding of OCD. Animal models of OCD are poised to play a vital role in extending the knowledge of the disorder now and in the future.

Animals↗

An unusual case of rhythmic movement disorder.

Rhythmic movement disorder is one of the sleep-wake transition disorders listed in the International Classification of Sleep Disorders. According to this classification, the condition commonly occurs in infants and toddlers, and persistence beyond 4 years of age is unusual. Recently, we encountered a case in which rhythmic movement disorder persisted up until the age of 12 years with spikes registering on the sleep electroencephalogram. Epileptic seizure was ruled out because of the characteristic rolling movement, absence of any other epileptic symptoms (e.g. vocalization and tonic-clonic seizure) and cessation as a result of removal of the blanket.

Child↗

Positive and negative psychotropic effects of lamotrigine in patients with epilepsy and mental retardation.

PURPOSE: To describe significant positive or negative psychotropic effects of lamotrigine (LTG) observed in epilepsy patients with mental retardation (MR). METHODS: Seven mentally retarded epilepsy patients, [5 with Lennox-Gastaut syndrome (LGS)] who experienced significant behavioral improvements or worsening after addition of LTG to their medication regimen were studied. RESULTS: LTG produced behavioral improvements in 4 patients. Patient 1, a 14-year-old girl, had LTG added to valproate (VPA) and thioridazine, resulting in diminished lethargy, less hyperactivity, and more appropriate speech. In a 17-year-old boy (patient 2) LTG added to VPA, phenytoin (PHT), and gabapentin (GBP) lessened irritability and hyperactivity. In patient 3, a 41-year-old woman, LTG added to PHT, VPA, and carbamazepine (CBZ) diminished lethargy and enhanced her social interactions. In patient 4, a 27-year-old man, LTG monotherapy diminished irritability and hyperactivity. Adverse behavioral effects were noted in 3 patients. In patient 5, a 43-year-old man, LTG added to PHT, phenobarbital (PB), lorazepam, sertraline, and thioridazine produced irritability, hyperactivity, and poor cooperation. In patient 6, a 29-year-old woman, LTG added to VPA produced frequent screaming, temper tantrums, increased rocking movements, and hyperactivity. In patient 7, a 29-year-old man, LTG added to VPA and PHT resulted in severe exacerbation of baseline behaviors, including self-injurious activity, temper tantrums, and failure to obey simple instructions. CONCLUSIONS: In some patients with epilepsy and MR, LTG has significant positive or negative effects on behavior.

Adolescent↗

A special type of head stereotypies in children with developmental (?cerebellar) disorder: description of 8 cases and literature review.

The authors report eight children, who presented in the first year of life with isolated head stereotypies, that corresponded neither to the usual normal 'rhythmic habit patterns of infancy', nor to various types of abnormal repetitive head movements described in young children. Their head stereotypies closely resembled those described in bobble-head doll syndrome. The neurological status evidenced axial hypotonia, ataxia, oculomotor abnormalities, motor and language delay. The patients were followed for several years clinically and with video recordings. No single aetiology was found. Computed tomography (CT) or magnetic resonance imaging (MRI) show a congenital cerebellar abnormality in two children but no hydrocephalus. The outcome of these children showed in all but one patient a normal cognitive and psychosocial development, even though the head stereotypies are still present in six of eight patients and all remain significantly clumsy. The association of head stereotypies and motor delay should prompt a search for cerebellar congenital malformation. The outcome of those patients was much better than originally anticipated and these head stereotypies are not related either to mental retardation, or to psychopathology. The possible mechanisms involved are also discussed.

Adolescent↗