PSYCHIATRY

RESEARCH
ELSEVIER Psychiatry Research 56 (1995) 183-204 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQ

The Cambridge Neurological Inventory: A clinical instrument

for assessment of soft neurological signs in psychiatric patients

Eric Y.H. Chenavb, Jane Shapleske”, Rogelio Luqued, Peter J. McKennac,

John R. Hodgese, S. Paul Callowayc, Nigel F.S. Hymasc, Tom R. Dening”,
German E. Berrios*b
“Department of Psychiatry, University of Hong Kong, Hong Kong.
bDepartment of Psychiatry, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK
‘Department of Psychiatry. Fulbourn Hospital, Cambridge, UK
‘Department of Psychiatry, University of Cordoba. Cordoba. Spain
‘Department of Neurology, University of Cambridge, Cambridge, UK

Received 17 August 1993; revision received 16 May 1994; accepted 13 June 1994

Abstract

A schedule (the Cambridge Neurological Inventory) has been constructed for standardized neurological assessment
of psychiatric patients. Normative data and data resulting from its application to a group of patients with
schizophrenia are reported. The instrument is comprehensive, reliable, and easy to administer. In conjunction with
other forms of clinical assessment, it may be useful for identifying soft neurological signs and other patterns of
neurological impairment relevant to neurobiological localization and prognosis in schizophrenia and other psychiatric
disorders.

Keywork Schizophrenia; Neurological soft signs; Motor coordination; Extrapyramidal signs

1. Introduction Mosher et al., 1971; Quitkin et al., 1976; Walker

and Green, 1982). The full significance of these
The term “soft neurological signs” refers to any signs has not been elucidated, although they are
neurological deviation - motor, sensory, or in- consistent with the view that schizophrenia is a
tegrative - that does not localize the site of a brain disease. Some of these signs are also present
putative central nervous system lesion (Quitkin et in relatives of patients with schizophrenia, sug-
al., 1976). Various neurological signs have been gesting that they might be a zyxwvutsrqponmlkjihgfed
trait marker (e.g.,
described in schizophrenia (Rochford et al., 1970; Rieder and Nichols, 1979; Marcus et al., 1985;
Kinney et al., 1991). An association with negative
* Corresponding author, Tel: +44 223 336965; Fax: +44 223 symptoms has also been reported (e.g., Merriam et
336968. al., 1990). In addition, soft signs have also been re-

0165-1781/95/W9.50 0 1995 Elsevier Science Ireland Ltd. All rights reserved

SSDI Ol65-1781(95)02535-5
184 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Erie Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

lated to formal thought disorder (Tucker et al., Despite the potential clinical significance of soft
1975; Manschreck et al., 1982; Schriider et al., neurological signs, few standardized instruments
1992) and neuropsychological impairment (e.g., have been developed, and those published to date
Liddle, 1987). Soft signs do not appear to be a are either restricted to a subset of signs or too
function of neuroleptic medication treatment (Cox lengthy for routine clinical use. The primary objec-
and Ludwig, 1979; Manschreck et al., 1982; tive of this study was to develop a standardized
Heinrichs and Buchanan, 1988). schedule to complement the basic neurological
It is important that soft neurological signs not examination and enable further neurological
be considered in isolation. Hard neurological signs assessment of psychiatric patients. We have at-
and other extrapyramidal signs are also frequently tempted to develop an instrument that can be ad-
present in psychiatric patients. Although most of ministered efficiently in routine clinical settings.
these are related to neuroleptic medication, in We further report the frequency of soft neuro-
some cases, they may be related to cerebral dys- logical signs and associated neurological findings
function underlying the psychosis (Owens et al., in a group of patients with schizophrenia.
1982; Rogers, 1992).
Hard signs such as the extensor plantar response 2. Methods
are sometimes present (Rochford et al., 1970;
Woods et al., 1986). Complex disorders of move- 2.1. Development of the neurological inventory
ment (e.g., echopraxia, stereotypies), which are In the first stage, an overinclusive preliminary
traditionally referred to as catatonic, may also be list of signs was compiled from a literature review,
associated with both soft neurological signs and including all signs of potential significance in
extrapyramidal signs (Manschreck et al., 1982; psychiatric disorders. Items were taken from
McKenna et al., 1991; Rogers, 1992). established descriptions and scales of soft
The precise relationship between soft neuro- neurological signs (Kinsbourne and Warrington,
logical signs and structural brain abnormality is 1962; Quitkin et al., 1976; Walker, 1981; Tweedy
not clear. Soft signs are traditionally regarded as et al., 1982; Jenkyn et al., 1985; Buchanan and
having less localizing value than conventional Heinrichs, 1989; Merriam et al., 1990), ex-
hard neurological signs. Nevertheless, some reg- trapyramidal signs (Simpson and Angus, 1970)
ional specificity has been argued on theoretical tardive dyskinesia (Simpson et al., 1979), and
grounds (Heinrichs and Buchanan, 1988). The re- catatonia (Lund et al., 1991). In addition, an
lationship between a particular sign and a cerebral abbreviated standard neurological examination
location is likely to be complex. Lateral ventricular was incorporated after consultation with a
enlargement on computed tomography (CT) has neurologist (J.R.H.). From the scales, all items of
been reported to be correlated with the presence of potential relevance were considered for inclusion.
soft neurological signs (Weinberger and Wyatt, Items were then omitted because of overlap or if
1982), although there have also been negative tind- inappropriate - for example, direct tests of higher
ings (Kolakowska et al., 1985; King et al., 1991). cognitive function (language, memory, and spatial
A recent study reported an association between a performance) and tests requiring additional exami-
particular subgroup of signs (motor coordination) nation equipment or procedures.
and size of the basal ganglia on CT scan (Schriider Operationalized instructions for eliciting and
et al., 1992). Previous research has failed to il- rating the signs were constructed. Where possible,
luminate the issues for a number of reasons, in- instructions and methods of elicitation followed
cluding such methodological problems as previously published work. Ratings were stan-
inconsistency of definition, lack of operational cri- dardized where appropriate to indicate normal re-
teria, construction of composite scores from sponse (0) equivocal response (OS), abnormal re-
heterogeneous items, and small sample sizes sponse (I), and grossly abnormal response (2). The
(Buchanan and Heinrichs, 1988). preliminary instrument was administered to 20 pa-
 Eric Y. H. Chen et al. /Psychiatry Research 56 (199s) 183- 204 185

tients by two examiners (E.Y.H.C. and P.J.M.), Table 1

each of whom made independent ratings. Inter- Demographic data for schizophrenic patients and control
rater reliability was computed only for soft subjects
neurological signs. This analysis was felt to be un-
necessary for hard neurological signs; reliability Control subjects Patients
(n = 100) (n = 62)
data have already been obtained for ex-
trapyramidal and catatonic signs (Lund et al.,
Male 66 41
1991). At this stage, several signs that were dif- Female 34 21
ficult to administer or rate were excluded (e.g., Mean age 40.17 41.36
blink rate and utilization behavior). A revised ver- SD 13.33 14.15
sion of the inventory was then constructed (see Right-handed 86 52
Left-handed 11 4
Appendix).
Mixed 2 I

2.2. Subjects Note. No significant difference at P = 0.05 (x2 test for sex and
Patients were selected from inpatient and outpa- handedness; two-tailed t test for age.
tient services according to the following criteria:
(1) Age 18-65; (2) DSM - III- R diagnosis of The full inventory required 20-40 min to
schizophrenia (American Psychiatric Association, complete.
1987); (3) No neurological or serious medical ill-
ness such as epilepsy, head injury, stroke, diabetes, 3. Results
and endocrine disorder; and (4) no history of sub-
stance abuse. All patients were receiving neurolep- Interrater reliability was analyzed with Ken-
tic medication. The mean daily medication dosage, dall’s w statistics for those signs that were not part
which was converted to chlorpromazine-equival- of a standard neurological examination or part of
ent dosage according to Davis (1974) was 1224 mg an already validated scale (see Table 2). Reliability
(SD = 1540 mg). was adequate for all relevant signs.
The control group consisted of paid volunteers
recruited from a local firm by advertisement. Sub- Table 2
jects with a history of psychotic illness, neuro- Interrater reliability for some of the soft neurological signs
logical disorder, or substance abuse were excluded
on the basis of a brief questionnaire. As most con- Sign Kendall’s w Significance
trol subjects were male, a small number of female level

subjects (n = 18) were recruited from the hospital

Finger-thumb opposition 0.88 0.023
staff. There were no significant differences in de-
Mirror movements (tinger- 0.82 0.041
mographic characteristics between patients and thumb opposition)
control subjects (Table 1). The National Adult Dysdiadochokinesia 0.91 0.018
Reading Test (Nelson, 1982) was used to assess Mirror movements 1 0.008
verbal intelligence in control subjects. The mean (dysdiadcchokinesia)
Fist-edge-palm test 0.85 0.035
estimated verbal IQ was 114 (SD = 0.7).
Oseretsky test 0.93 0.017
The revised inventory was applied to 100 normal Rhythm tapping 0.91 0.04
control subjects and 62 patients with schizo- Go/no-go test 1 0.008
phrenia. Assessments were performed by three Extinction 0.87 0.026
members of the research group (E.Y.H.C., R.L., Finger agnosia 0.97 0.01
Stereoagnosia 0.95 0.01 I
and J.S.) who had been trained in the use of the
Agraphesthesia 0.93 0.015
schedule. Handedness was assessed clinically. To Left-right disorientation I 0.008
maximize interrater reliability and efficient use of Glabellar tap 0.92 0.016
the schedule, 5-10 training sessions were required.
186 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183-204

Table 3 presents the prevalence of individual to their nature, following the approach suggested
signs in patients and in the control group, together by Buchanan and Heinrichs. Not all signs fell into
with x2 statistics (with Yates correction where ap- one of the subgroups, and there was no attempt to
propriate). Further analyses were carried out with force all the signs into one group or other. The
signs grouped together, where possible, according categories were as follows: (1) Hard neurological

Table 3
Prevalence of signs in schizophrenic patients and control subjects

Signs Normal % Patients % x2 Significance level

(n= 100) (n = 62)

Articulation 0 0.00 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

6 9.68 17.20 0.0006
Aprosody 0 0.00 I2 19.35 22.80 <0.0001
Unintelligible 0 0.00 5 8.06 10.05 0.02
Extent SPEM 4 4.00 5 8.06 I .92 NS
Smoothness SPEM 4 4.00 II.29 5.56 NS
Gaze impersistence 3 3.00 13 20.91 16.10 0.001 I
Smoothness saccade 5 5.00 9 14.52 5.99 NS
Saccade blink I2 12.00 27 43.55 14.90 < 0.0001
Saccade head 3 3.00 I7 27.42 22.90 <0.0001
Wink I2 12.00 25 40.32 19.27 0.0002
Glabellar sign I 7.00 25 40.32 30.79 <O.OOOl
Rapid tongue movement 6 6.00 29 46.11 39.04 <O.OOOl
Impersistent tongue
movement 0 0.00 6 9.68 10.05 0.0066
Extensor plantar 5 5.00 4 6.45 3.70 NS
response, left
Extensor plantar 5 5.00 5 8.06 1.50 NS
response, right
Upper limb hypertonia 2 2.00 I8 29.03 26.40 <0.0001
Upper limb hyperreflexia 5 5.00 2 3.23 1.98 NS
Upper limb hypotonia 0 0.00 I.61 0.05 NS
Upper limb weakness 0 0.00 2 3.23 I.15 NS
Upper limb hyporetlexia IO 10.00 9 14.52 4.16 NS
Lower limb hypertonia 2 2.00 II 17.74 13.23 0.0013
Lower limb hyperretlexia 3 3.00 5 8.06 6.40 NS
Lower limb hypertonia 0 0.00 I.61 0.06 NS
Lower limb weakness 0 0.00 I.61 0.06 NS
Lower limb hyporeflexia 4 4.00 9 14.52 8.64 0.03
Snout reflex I 1.00 II 17.74 17.56 0.0005
Grasp reflex 0 0.00 4 6.45 6.61 0.03
Palmomental reflex 0 0.00 6 9.68 10.38 0.0055
Finger-nose+ left I 1.00 I.61 3.86 NS
Finger-nose, right 0 0.00 2 3.23 1.15 NS
Finger-thumb tapping, left 0 0.00 I3 20.91 23.50 <0.0001
Finger-thumb tapping, 0 0.00 I4 22.58 26.20 <0.0001
right
Finger-thumb opposition, 7 7.00 28 45.16 36.40 <O.OoOl
left
Finger-thumb opposition, 8 8.00 23 37.10 26.04 <O.OOOl
right
Mirror movement I, left IO 10.00 6 9.68 0.36 NS
Mirror movement I, right zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
II II.00 5 8.06 1.80 NS
 Eric Y. H. Chen et al. /Psychiatry Research 56 (I995) 183- 204 187

Table 3 (Continued)

Signs Normal % Patients % zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONM

X2 Significance level
(n = 100) (n = 62)

Dysdiadochokinesia, left 7 7.00 I8 29.03 25.48 <O.OOOl

Dysdiadochokinesia, right 3 3.00 I7 27.42 22.50 0.0001
Mirror movement 2, left 3 3.00 I 1.61 0.41 NS
Mirror movement 2, right I6 16.00 2 3.23 7.64 0.02
Fist-edge-palm, left I4 14.00 42 61.74 59.28 <O.OOOl
Fist-edge-palm, right 8 8.00 41 66.13 66.18 <O.OOOl
Oseretsky sign I2 12.00 34 54.84 39.45 <O.OOOl
Rhythm tapping 41 41 37 59.68 14.33 0.0008
Go/no-go test I I II 17.74 19.14 0.0007
Extinction I I 15 24. I9 24.57 <O.OOOl
Finger agnosia, left 32 32 34 54.84 16.08 0.0003
Finger agnosia, right 30 30 30 48.39 9.20 0.01
Stereognosis, left 6 6 17 27.42 18.34 0.0001
Stereognosis, right 9 9 I4 22.58 7.44 0.024
Graphesthesia, left I8 I8 39 62.90 38.59 <O.OOOl
Graphesthesia, right I5 IS 35 56.45 37.12 <O.OOOl
Left-right disorientation I6 I6 24 38.71 12.33 0.006
Gait increased 0 0 5 8.06 6.18 0.01
Gait decreased 0 0 I4 22.58 34.40 <O.OOOl
Gait shutlling 0 0 7 11.29 14.28 0.0026
Gait mannerism 0 0 3 4.84 6.95 NS
Facial dyskinesia 0 0 I5 24.19 31.70 <O.OOOl
Face simple 0 0 I 1.61 0.06 NS
Face complex 0 0 1 I.61 0.06 NS
Gegenhalten 0 0 2 3.23 3.37 NS
Mitgehen 0 0 8 12.90 15.41 0.0015
Trunk simple 0 0 5 8.06 10.38 0.0155
Trunk complex 0 0 2 3.23 6.80 0.03
Imposed posture 0 0 8 12.90 14.45 0.0007
Trunk limb dyskinesia 0 0 I9 30.65 35.96 <O.OOOl
Trunk limb simple 0 0 I I.61 0.06 NS
Trunk limb complex 0 0 2 3.23 1.20 NS
Pronator drift 0 0 8 12.90 16.45 0.0009
Arm dropping 0 0 I6 25.81 29.60 <O.OOOl
Tremor I I I6 25.81 27.38 <O.OOOl
Romberg’s sign 0 0 I 1.61 0.06 NS
Balance 4 4 I4 22.58 21.45 0.0003
Walk 0 0 0 0.00
stop 0 0 0 0.00
Turn 0 0 0 0.00
Tandem walking I I 6 9.68 8.00 0.018
Abrupt movement 0 0 4 6.45 8.60 0.01
Slow movement I I 9 14.52 12.59 0.0018
Exaggerated movement 0 0 4 6.45 4.37 0.036
Iterative movement 0 0 0 0.00
Other movement 0 0 2 3.23 8.60 0.013
Mutism 0 0 3 4.84 2.74 NS
Neck rigidity 0 0 5 8.06 6.43 0.01 I
Overactivity 0 0 0 0.00
Underactivity 0 0 10 16.13 19.68 0.0002
Automatism 0 0 1 1.61 0.06 NS
188 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

Table 3 (Continued) zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Signs Normal % Patients % X2 Significance level

(n = 100) (n = 62)

Noncompliance 0 0 2 3.23 3.37 NS

Abnormal behavior 0 0 0 0.00
Echophenomena 0 0 8 12.90 15.36 0.0015
Perseveration 0 0 6 9.68 15.62 0.0004

Note. NS, P > 0.05. SPEM, smooth pursuit eye movement.

signs - plantar reflexes; power and reflexes in ex- For each of these categories, a summary score
tremities. (2) Motor coordination - finger-nose was calculated for each subject by adding up
test; finger-thumb tapping; finger-thumb opposi- scores of the relevant signs. Comparisons between
tion; dysdiadochokinesia; fist-edge-palm test; patients and control subjects were carried out for
Oseretsky test. (3) Sensory integration - extinc- each group of signs with the Mann-Whitney U
tion; finger agnosia; stereoagnosia; agraphes- test. In all categories except hard neurological
thesia; left-right disorientation. (4) Primitive signs, there was a significant difference between
reflexes - snout reflex; grasp reflex; palmo-mental patients and control subjects (Table 4). Certain
reflex. (5) Tardive dyskinesia - simple, complex, groups of signs were positively correlated with one
and dyskinetic abnormal involuntary movements another. In particular, two traditional soft sign
in the face, trunk, and limbs. (6) Catatonic signs - groups (motor coordination and sensory integra-
gait mannerism; gegenhalten; mitgehen; imposed tion) were correlated. In addition, motor incoor-
posture; abrupt or exaggerated spontaneous move- dination signs were associated with catatonic signs
ments; iterative movements; automatic obedience and parkinsonism. Primitive reflexes were cor-
and echopraxia. (7) Parkinsonism - increased related with catatonic signs (Table 5).
tone in limbs; decreased associated movements in Within the group of patients with schizophrenia,
walking; shuffling gait; arm dropping; tremor; no significant correlation was found between
rigidity in neck. (8) Failure to suppress inappropri- dosage of neuroleptic medication and scores in any
ate response - blinking in saccadic eye move- of the categories of signs. There was also no signi-
ments; head movement in saccadic eye movements; ficant correlation with the global score.
winking with one eye.

Table 4
Comparison of scores in groups of signs between schizophrenic patients and control subjects

Control mean Patient mean II W 2 P

rank rank

Hard signs 74.65 84.09 2415 4625 -1.59 NS

Motor coordination 59.56 113.88 906 6605 -7.54 <O.OOOl
Sensory integration 64.30 105.71 1380 6131 -5.59 <0.0001
Primitive reflexes 71.29 95.84 2079 5750 -5.65 <0.0001
Tardive dyskinesia 66.98 103.03 1648 6128 -6.91 <O.OOOl
Catatonic signs 66.90 102.20 1640 6030 -6.31 <0.0001
Extrapyramidal signs 62.05 105.31 1193 5792 -7.49 <0.0001
Suppression failure 65.11 106.16 1460 6369 -6.08 <O.OOOl

Note. Mann-Whitney lJ and Wilcoxon rank sum W tests were carried out.
 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183-204 189

Table 5
Pearson correlation coefficients between groups of neurological signs

Motor co- Sensory inte- Primitive Tardive Catatonic Extrapyra- Suppression

ordination gration reflexes dyskinesia signs midal signs failure

Hard signs 0.2302 0.1191 -0.259 0.2072 0.0336 0.0374 0.1289

[0.003] [0.078] [0.379] [0.006] IO.3451 [0.328] [0.062]
Motor 0.6658 0.385 0.3183 0.4169 0.5361 0.3963
coordination [<O.ool] [<O.ool] [<O.OOO] [ < 0.ooo] [<O.ool] [<O.ool]
Sensory 0.2478 0.2934 0.3134 0.4369 0.343
integration [O.OOl] [<0.0011 [<O.OOl] [<O.OOl] [<O.OOl]
Primitive 0.2027 0.4613 0.2151 0.1052
reflexes [0.00711 [<O.OOl] [O.OOS] [O.1051
Tardive 0.15 0.4506 0.1155
dyskinesia [0.036] [<O.OOl] [0.084]
Catatonic 0.4663 0.3786
signs [<O.OOl] [<O.OOl]
Extrapyramidal 0.2263
signs [O.OOl]

Note. The level of statistical significance is shown in brackets (n = 144).

4. Discussion tion to clinical situations. Operational definitions

have been used to promote reliability, but space is
This article reports the development of a sched- also provided for more descriptive comments that
ule for neurological examination with particular may carry important information. We have tried
application to psychiatric patients. The instrument to achieve a compromise between an emphasis on
takes 20-40 min to administer and is adequately reliability and an allowance for items related to
reliable after initial training has been performed. more complex behavioral patterns with volitional
The inventory requires at least live practice trials and contextual influences (e.g., perseveration,
before clinical use. For research purposes, it would echophenomena). The schedule is designed to
also be necessary to reestablish adequate reli- complement the standard neurological examina-
ability. tion, and it is assumed that other important as-
The schedule differs from others previously pects (e.g., cranial nerve and sensory assessment)
published in having a wider scope and more will also be considered.
precise operational definitions for eliciting signs. The study was not designed to assess the effects
Other scales have tended to concentrate on soft of age on soft neurological signs. In attempting to
neurological signs or extrapyramidal signs. There validate the scale, we matched patient and control
is also a tendency simply to add item scores to pro- groups for age. A comparison of the younger and
duce a global score. We suggest that the profile of older halves of the groups revealed no significant
subsets of signs yields more information. Our in- difference in the number of signs in each subgroup
strument is thus not a scale, but rather an inven- apart from motor coordination signs, with higher
tory. Because the inventory contains a range of scores for the older half in patients zyxwvutsrqponmlkji
(P = 0.016,
different types of signs, however, it would be pos- Mann-Whitney U test) and control subjects
sible to develop scales based on subsets of signs (P = 0.005, Mann-Whitney U test); and sensory
(e.g., soft neurological signs, catatonic signs). integration signs in patients (P = 0.002, Mann-
We have included signs irrespective of their Whitney U test). Further exploration of this issue
presumed etiology, and we have sought a balance would require a differently designed study.
between comprehensiveness and practical applica- Our findings in patients with schizophrenia are
190 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

consistent with previous reports. Assessment of Kinney, D.K., Deborah, A., Yurgelun-Todd, D.A. and
such patients with the scale compared with 100 Woods, B.T. (1991) Hard neurological signs and
psychopathology in relatives of schizophrenic patients.
control subjects showed that patients were more
Psychiatry Res 39, 45- 53.
likely to have not only an increased incidence of Kinsboume, M. and Warrington, E.K. (1962) A study of linger
soft neurological signs but also of tardive agnosia. Brain 85, 47- 66.
dyskinesia, catatonia, and extrapyramidal signs. In Kolakowska, T., Williams, A.O. and Jambor, K. (1985)
contrast, the prevalence of hard signs did not dif- Schizophrenia with good and poor outcome: III.
neurological ‘soft’ signs, cognitive impairment and their
fer significantly between patients and control sub-
clinical significance. b J Psychiatry 146, 348- 357.
jects. The absence of a significant difference in the Liddle, P.F. (1987) Schizophrenic syndromes, cognitive perfor-
prevalence of hard signs is contrary to some pre- mance and neurological dysfunction. Psy cho1 M ed 17,
vious findings (Rochford et al., 1970; Woods et al., 49- 57.

1986) and may be due to differences in the items Lund, C.E., Mortimer, A.M., McKenna, P.J. and Rogers, D.
(1991) Motor, volitional and behavioural disorders in
included as hard signs. When patients and control
schizophrenia: I. assessment using the Modified Rogers
subjects were compared, signs seemed to fall Scale. Br J Psychiatry 158, 323- 327.
broadly into three groups, of which the first two zyxwvutsr
McKenna, P.J., Lund, C.E., Mortimer, A.M. and Biggins, zyxwvutsrqpon
C. A.
are likely to be of most interest for future research: (1991) Motor, volitional and behavioural disorders in
(1) Signs that are infrequent but present in a small schizophrenia: 2. The ‘conflict of paradigms’ hypothesis. Br
J Psychiatry 158, 328-336.
number of patients and never observed in control
Manschreck, T.C., Maher, B.A., Rucklos, M.E. and Vereen,
subjects; (2) signs that are present in both patients D.R. (1982) Disturbed voluntary motor activity in
and control subjects but significantly more fre- schizophrenic disorder. Psy cho1 Med 12, 73-84.
quent in patients; and (3) signs that are present Marcus, J., Hans, S.L., Mednick, S.A., Schulsinger, F. and
equally often in patients and control subjects. Michelsen, N. (1985) Neurological dysfunctioning in off-
spring of schizophrenics in Israel and Denmark: a replica-
Finally, although the schedule was constructed
tion analysis. Arch Gen Psychiatry 42, 753- 761.
and validated in patients with schizophrenia, it Merriam, A.E., Kay, S.R., Opler, L.A., Kushner, S.F. and van
would also be suitable for studies of other psychia- Praag, H.M. (1990) Neurological signs and the positive-
tric conditions such as obsessive-compulsive disor- negative dimension in schizophrenia. Biol Psychiatry 28,
der, affective disorder, and dementia. 181- 192.
Mosher, L.R., Pollin, W. and Slabenaw, J.R. (1971) Identical
twins discordant for schizophrenia: neurological findings.
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senescence. Arch Neural 42, I 154- 1157. Schriider, J., Niethammer, R., Geider, F., Reitz, C., Binkert,
King, D.J., Wilson, A., Cooper, S.G. and Waddington, J.L. M., Jauss, M. and Sauer, H. (1992) Neurological soft signs
(1991) The clinical correlates of neurological soft signs in in schizophrenia. Schizophr Res 6, 25- 30.
chronic schizophrenia. Br J Psychiatry 158, 770-775. Simpson, G.M. and Angus, J.W.S. (1970) Drug induced ex-
 Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 191

trapyramidaldisorders.Acta Psychiatr &and, Suppl. 212, rating in the space provided. Additional informa-
l- 58.
tion is advisable if ratings 0.5 or 9 are selected. Do
Simpson,GM., Lee, J.H., Zoubok, J.H. and Gardos, GA.
(1979) Rating scale for tardive dyskinesia. Psychophar-
not use rating “2” if a test can only be either posi-
macology 64, 17 I- 179.
tive or negative; such dichotomous items - for ex-
Tucker, G.J., Campion, E.W., and Silberfarb, P.M. (1975) Sen- ample, extensor plantar response - are indicated
sorimotor functions and cognitive disturbance in psychiatric in the item description.)
patients. Am J Psychiatry 132, 17- 21. Note: If an item is abnormal due to known
Tweedy, J., Reding, M., Gracia, C., Schulman, P., Deutsch, G.
preexistent pathology (e.g., sensory neuropathy
and Antin, S. (1982) Significance of cortical disinhibition
signs. Neurology 32, l69- 173. secondary to diabetes or ophthalmoplegia second-
Walker, E. (1981) Attentional and neuromotor functions of ary to thyroid eye disease), then “9” should be
schizophrenics, schizoaffectives and patients with other af- rated and an appropriate note made alongside the
fective disorders. Arch Gen Psychiatry 38, 1355- 1358, item.
Walker, E. and Green, M. (1982) Soft signs of neurological
dysfunction in schizophrenia: an investigation of lateral per-
formance. Biol Psychiatry 17, 381- 386.
Weinberger, D.R. and Wyatt, R.J. (1982) Cerebral ventricular Part I
size: a biological marker for sub-typing chronic schizo-
phrenia. In: Usdin, E. (Ed.), Biological M arkers in Psychiatry Speech
and Neurology . Pergamon Press, Oxford, pp. 505-512.
Patient is engaged in casual conversation for up
Woods, B.T., Kinney, D.K. and Yurgelun-Todd, D. (1986)
Neurological abnormalities in schizophrenic patients and
to 3 min. Introduction to the examination and in-
their families: I. comparison of schizophrenic, bipolar and struction to relax are given.
substance abuse patients and normal controls. Arch Gen l Poor articulation: Rate during 3 min of casual
Psychiatry 43, 657- 663. conversation. Difficulty in producing pho-
netically clear speech is rated.
Appendix: Cambridge Neurological Inventory 0 - Normally understandable
1 -Patient must repeat to be understood on
Instructions and item descriptions several occasions
2 - Almost incomprehensible
Overall testing procedures l Aprosodic speech: Simply unvarying; harsh or
Part 1: Assessment of speech; assessment of eye stereotyped inflections should not be rated
movements; assessment of cranial nerves; Extremi- unless marked (e.g., unnaturally loud, stri-
ty examinations (tone, strength, reflex). dent, high-pitched, or alternatively feeble,
Part 2: Soft sign examinations (primitive whispering, or completely monotonous in-
reflexes; repetitive movement; sensory integra- tonations). Occasionally also automaton-like,
tion). singsong, rasping, strangled, or warbling in-
Part 3: Assessment of posture and movements flections.
(including catatonia and tardive dyskinesia). 0 - No abnormality
Equipment required: tendon hammer, tongue de- 1 - Clear loss of normal inflections
pressor, pen, torch, a set of 5-10 small commonly 2 - Unnatural strange intonations as described
encountered objects (coin, paper clip, match, eras- above
er, rubber band, screw, battery, shell, button). l Unintelligible speech: Mumbling, nonsocial
Instruction: Enter rating in scoring sheet within speech, self-muttering, not merely due to poor
[ ] space provided. Enter additional remarks in the articulation. Do not rate mere incoherent
following space [ 1. Unless otherwise specified, rate speech due to formal thought disorder.
as follows: 0 = normal, 0.5 = subthreshold, 0 - No abnormality
1 = definitely abnormal, 2 = grossly abnormal, 1 - On few occasions, otherwise can engage in
9 = missing, unable to test, or lack of cooperation conversation
or comprehension. 2 - For more than a substantial period of time
(Additional description can be entered next to (10 min) during interview
192 Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183-204

Assessment of eye movements (“I am going to test two horizontal saccades. (Examiner: “I notice
your eyes next’) you tend to blink while you do this; see if you
There are two main components: (1) smooth could do it without blinking”).
pursuit eye movements and (2) saccadic eye move- 0 - No blinks
ments. Each of the two components should be con- 1 - Unable to stop blinks on occasions even after
ducted sequentially and ratings completed repeated instruction
afterward. 2 - Unable to stop blinks on all saccades
1. Smooth pursuit eye movements: Patient is l Lateral head movements during saccades: The
asked to focus on a slowly moving target (e.g., a co-occurrence of lateral head movement
pencil or pen) at a distance that the patient can (usually in the same direction) with saccades
focus on. The target is moved slowly in a horizon- is observed. (Examiner: “You tend to move
tal and then in a vertical direction. (Examiner: your head when you do this; see if you could
“Could you follow the [e.g., pen] with your eyes, do it without moving the head”).
keeping the head still”). 0 - None
l Extent of smooth pursuit eye movements: 1 - Head moves with eyes, unable to suppress on
Rate as positive if range of movement is clear- some occasions even after instruction
ly restricted. Do not rate if there is obvious 2 - Head moves with eyes on all occasions
proptosis or unilateral ophthalmoplegia.
l Smoothness of smooth pursuit eye move- Selective assessment of cranial nerves
ments: Rate as positive if noticeably “catchy” This part could be completed and scored either
or jerky; only clear instances are rated item by item or as a unit, depending on the exam-
l Gaze impersistence: Patient is asked to fix iner’s familiarity with the assessment.
his/her gaze on an object (e.g., a pen) at a 45” l Wink with other eye open: (Examiner: “Could
angle in the horizontal plane of the right and you wink with the other eye open, like this”
then left visual fields for 15 s each. (Examiner: [Demonstrate].) If lateralized, indicate the
“Could you keep looking at this [pen] with side in which unilateral blinking is difficult.
your head still, until I tell you to stop”). l Glabellar tap: Patient is instructed to fix
0 - No deviation from fixation his/her gaze on a distant point across the
1 - Deviation from fixation on one or two occa- room or outside the room. After explanation,
sions but able to resume gaze the patient is approached from above the
2 - Deviation from fixation repeatedly; unable to forehead outside of the visual field, and the
resume gaze examiner taps the glabellar region 10 times
2. Saccadic eye movements: Hold one target at with the index linger. If the spontaneous blink
the right extreme of lateral vision and the other rate is high, the patient is asked to relax, and
target at the left extreme of lateral vision. Patient the blinking pattern is carefully observed
is asked to look at one of the targets and then before the taps are applied. (Examiner: “I am
quickly at the other (“as fast as possible, to and fro going to tap your forehead gently. Just try to
for several times”). Observe for smoothness of relax and look ahead at the [fixation point].“)
movement, presence of blinking and head move- 0 - One to three blinks (include partial blinks)
ment. (Examiner: “Could you look at the [pen]... 1 - More than three blinks with some habituation
and then at this (torch)... and back to the [pen]. (reduction of tendency to blink when tapped)
Do this a few times as quickly as you can”). 2 - No habituation at all
l Smoothness of saccade movements l Rapid tongue movements: Touch corners of
0 - One smooth movement mouth with tip of tongue alternately.
1 - Slight jerky movements [Demonstrate] (Examiner: “Coul# you stick
2 - Extremely jerky movement the tongue out and move it as quickly as you
l Blink suppression during saccades: The co- can between the two corners of the mouth.“)
occurrence of blinking is looked for during 0 - Normal (> 4 touches/s)
 Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 193

1 - Slow (< 4 touches/s) l Upper limb hy poreflexia

2 - Very slow or dysrhythmic 0- Normal
l Impersistence- tongue protrusion: Hold tongue 1 - Reflex absent
out (without using the teeth) for 15 s. (Exam- 2. Lower limb assessment (Examiner: “I am
iner: “Could you keep the tongue out until I going to examine your legs now. Could you take
tell you to stop.“) off your shoes and socks?” fThis is a good point
0 - Maintains act for 20 s to observe ambitendence but the rating can be
1 - Retracts tongue before 20 s on one or two oc- entered later: Part 3.1
casions but is able to resume test l Lower limb tone.
2 - Retracts tongue before 20 s and unable to 0 - Normal
complete test 1 - Definitely increased or decreased
2 - Grossly increased or decreased
Extremity examinations l Lower limb strength (Examiner: “Could you
These examinations of tone, strength, and straighten your leg” “Could you point the
reflexes in the upper and lower limbs are perform- toes toward you”).
ed as a unit with the patient seated. Scores are 0 - Normal
entered on the page after the entire block of exami- 1 - Decreased
nation. l Lower limb hy perreflexia.
1. Upper limb examination (Examiner: “I am 0 - Normal
going to examine your arms next.“) 0.5 - Equivocal
l Upper limb tone: Flexion-extension, pro- 1 - Positive
nation-supination of the elbow joint; and 9 - Missing
flexion-extension of the wrist joints are exam- l Lower limb hy poreflexia.
ined. The degree of resistance from normal to 0 - Normal
extreme rigidity (hypertonia) or to extreme 1 - Reflex absent
flaccidity (hypotonia) is scored. Proper in- 3. Extensor plantar reflex: The plantar reflex is
struction to relax is important. It is advisable elicited by a firm stroke on the outer border of the
that the patient’s arms be moved without any sole with a blunt pointed object (e.g., a key); an ex-
regular rhythm or pattern. (Examiner: “Could tensor response is observed where there is exten-
you relax and let your arm go as soft as possi- sion of the big toe and outward fanning of the
ble while I hold it.“) (Note: Scored for in- digits.
creased tone.) 0 - Normal
0 - Normal 0.5 - Equivocal
1 - Slight to moderate stiffness and resistance 1 - Extensor
2 -. Marked rigidity with difficulty in passive [End of Part 1: This is a good point to allow the
movement patient to have a short break before proceeding to
l Upper limb strength (Examiner: “Could you Part 2. Examiner: “Would you like to take a break
grasp my fingers as hard as you can.” “Could for a little while?“]
you pull me toward you”).
0 - Normal Part 2
1 - Decreased
2 - Markedly reduced Soft signs assessment
l Upper limb hy perreflexia: Rating for all reflex There are mainly three groups: The first group
items. of soft sign tests assesses some “primitive
0 - Normal reflexes.” The second group is concerned with re-
0.5 - Equivocal petitive sequential motor execution. The third
1 - Positive group consists of tests related to integration of
9 - Missing sensory information. The patient is seated facing
194 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

the examiner (seated opposite). Each test is per- 1 - One or two minor mistakes, slow (< l/s) or
formed and rated before the examiner goes on to clumsy (e.g., gross presence of associated move-
the next test. ments in other parts of the hand and forearm), but
l Snout reflex: After explanation, the patient is no major disruption of movements
instructed to relax, and the examiner rests a 2 - Major disruption (e.g., total loss of rhythm or
tongue depressor against the patient’s precision) or repeated breakdowns of sequence
philtrum and taps gently with the index l Finger- thumb opposition: The patient is asked
finger. (Examiner: “Could you close your eyes to place both hands palm up with lingers fully
and relax. I am going to tap gently on your extended on his/her legs. The patient is to
mouth.“) start with his/her dominant hand and is to
0 - No contraction of the orbicularis orris touch the tip of his/her fingers with the tip of
1 - Any contraction of the orbicularis orris his/her thumb, from index finger to little
l Grasp reflex: The patient is instructed to relax finger, returning to index finger, for a total to
and the palm is stroked lightly with the exam- 10 repetitions. (Examiner: “Now could you
iner’s index linger. The sign should be demon- do this [demonstrate] and repeat 10 times.
strable at least twice on repetition Start now.” [Observe for mirror movement].)
0 - No movement of patient’s hand 0 - Normal
1 - Some flexion of fingers 1 - One or two minor mistakes, slow (< l/s) or
2 - Examiner’s finger grasped clumsy (e.g., gross presence of associated move-
l Palmomental rejlex: The patient is instructed ments in other parts of the hand and forearm), but
to relax. Muscle activity around the lips is no major disruption of movements
observed. The thenar eminance (of the left 2 - Major disruption (e.g., total loss or rhythm or
and then right hand in turn) is then stroked precision) or repeated breakdown of sequence
vigorously with a blunt pointed object. In- l M irror movements (I): The patient’s hand,
duced movement of the mentalis muscle is which is not performing the finger-thumb op-
observed. If a positive response is gained from position test, is observed for mirror move-
either hand, then it is rated as positive. If ments (tendency for the resting hand to move
elicited unilaterally, please indicate in the in a way symmetrical to the performing hand)
space provided, the stimulus in which side of 0 - No observable movement zyxwvutsrqponmlkjihgfedcba
the hand led to response in which side of the 1 - Minor movements of the fingers
face. (Examiner: “I am going to stroke the 2 - Consistent, distinctive movements of the
palm. Could you close your eyes and relax.“) lingers
0 - No movement observed l Diadochokinesis: The patient is asked to make
1 - Movement of the mentalis muscle a fist with one hand and pat the back of the
l Finger- nose test: The patient is instructed to fist with the other hand alternately using the
close eyes and touch the tip of his/her nose palm and the dorsum. Demonstrate five
with the tip of his/her index finger. (Examiner: times; rate as finger-thumb opposition
“Could you close your eyes and touch your 0 - Normal
nose with this finger.“) [Patient’s index finger 1 - One or two minor mistakes, slow (< l/s) or
is touched.] clumsy (e.g., gross presence of associated move-
0 - No intention tremor or pastpointing ments in other parts of the hand and forearm), but
1 - Mild intention tremor or pastpointing no major disruption of movements
2 - Marked intention tremor or pastpointing 2 - Major disruption (e.g., total loss of rhythm or
l Finger- thumb tapping: The patient is asked to precision) or repeated breakdown of sequence
touch tip of thumb with tip of index finger as l M irror movements (2): During the test for
quickly as possible. (Examiner: “Could you dysdiadochokinesia, the patient’s resting
do this? [Demonstrate]. Now start.“) hand, holding a fist, is observed for mirror
0 - Normal movements (pronation-supination).
 Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 195

0- No observable movement stimulus sequence suggested). (Examiner: “I

1- Minor pronation or supination movements am going to tap some sound on the table like
2- Consistent, distinctive pronation and supina- this; some taps are louder than others
tion movements of the forearm [demonstrate]. Could you tap the same
l Fist-edge-palm test: The patient is shown the rhythm back to me? Now close your eyes and
task and then asked to perform the following: listen.“)
using a smooth and steady rhythmic pattern,
to touch the table with the side of his/her list,
Stimulus sequence Response
the edge of his/her hand, and the palm of
his/her hand. The patient is to break contact ** ** * *
with the surface of the table between each . * . * . *
change in hand position, but not to bring the
* . . l . . * . .
arm back in full flexion. The patient is to re-
+ 1
peat this sequence of position changes 10 * . . .

times. (Examiner: “Watch me do this.” . .* . . *

[Demonstrate five times, without verbal in- . = light tap; l = loud tap. Horizontal distance between taps
struction.] “Now see if you can do it.” corresponds to length of pauses.
[Repeat demonstration once if patient fails to
perform.])
0 - No error
0 - Normal 1 - One error (either in loudness or rhythm)
1 - One or two minor mistakes, slow (C l/s) or 2 - Two or more errors
clumsy (e.g., gross presence of associated move-
ments in other parts of the hand and forearm), but
no major disruption of movements l Go/no-go test: The patient is asked to tap the
2 - Major disruption (e.g., total loss of rhythm or table once if the examiner taps the table once,
precision) or repeated breakdowns of sequence but not to tap if the examiner taps the table
l Oseretsky test: The patient is to place both twice. Give adequate demonstration and
hands on the table, one hand palm down and practice to ensure comprehension of task.
the other hand in the shape of a fist. The pa- Before proceeding, the examiner asks the pa-
tient to describe what he/she is supposed to
tient is then asked to simultaneously alternate
the position of his/her hands in a smooth and do. (Examiner: “If I tap once on the table like
steady motion. The patient is asked to repeat this [demonstrate], could you tap once. If I
this motion 15 times. Synchrony in change of tap twice on the table like this [demonstrate],
please do not tap.“)
position is observed. (Examiner: “Watch me
do this.” [Demonstrate five times.] “Now see
if you can do it.” [Repeat demonstration once
only if patient fails to perform.])
Stimulus * * * * * * *
0 - Normal Response
1 - Minor mistakes, but no major desynchroniza-
tion of movements
2 - Total desynchronization or repeated break-
down of sequence 0 - No error
1 - One error
l Rhythm-tapping test: Ask the patient to re- 2 - Two or more errors
produce exactly the series of taps heard while l Extinction: The patient is seated, with hands
the patient has eyes closed (live trials using resting palm down, on his/her knees and with
196 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

eyes closed. The patient is told that he/she will proper care being taken to ensure that the pa-
be touched on the cheek, the hand, or both tient does not look at the object. Suggested
and that he/she is to say where he/she has objects are: paper clip, coin, rubber band,
been touched. If the patient names just one eraser, screw, small seashell, or match).
touch, he/she is asked (the first time this oc- (Examiner: “Could you close your eyes and
curs only) if a touch is felt anywhere else. tell me what this object is, just by feeling it.“)
Simultaneous touching is performed in the 0 - No error
following order: right cheek-left hand, left I- One error
cheek-right hand, right cheek-right hand, left 2 - Two or more errors
cheek-left hand, both hands, and both cheeks. l Graphesthesiu: The patient, with eyes closed,
Intact sensation to touch is confirmed in each is asked to identify the number written on
test area beforehand. (Examiner: “I am going his/her palm with a blunt point, the number
to touch your face and your hand like this being orientated facing the patient. Five trials
[demonstrate]. Could you tell me which side for each hand. Stimulus can be repeated once
of the face and the hand I am touching. For upon request by the patient or when the pa-
example...[demonstrate]. Now close the tient gives a response other than a number.
eyes.“) (Examiner: “I am going to trace a number on
0- No error your palm; for example, this would be a
1- One error [number].” [Demonstrate.] “Could you tell
2- Two or more errors me what the number is, with your eyes
l Finger ugnosia: With the patient facing the closed.“)
examiner, hands palm down on the table, 0 - No error
fingers spread, and eyes closed, the examiner 1 - One error
simultaneously touches two of the patient’s 2 - Two or more errors
fingers. The patient is asked to state the num- l Left-right orientation: [The examiner should
ber of lingers between the two touched. The remove wristwatch before the test] The pa-
answer may be 0, 1,2, or 3. A total of five tri- tient is asked to point to his/her right foot, left
als for each hand is tested. See scoring sheet hand; place his/her right hand to left shoul-
for test sequence: 1 for thumb, 5 for last der, left hand to right ear; point to the exam-
finger, etc. (Examiner: “Could you put your iner’s left knee, then right elbow; with
hand on the table like this [demonstrate]. I am examiner’s arms crossed, point to examiner’s
going to touch two of the fingers like this left hand with his/her right hand, and with
[demonstrate]. I’d like you to tell me how examiner recrossing arms, point to examiner’s
many fingers there are in between the ones right hand with his/her left hand. (Examiner:
that I am touching. For example, this will “Could you point to - with your
be...[demonstrate]. Now close your eyes.“) ,,
)
0- No error 0 - Noror
1- One error 1 - Left/right disorientation confined to percep-
2- Two or more errors tion of another person
l Stereognosis: The patient, with eyes closed, is 2 - Left/right disorientation in self-body space
asked to identify an object placed in his/her [End of Part 2: Another break can be taken at
hand. The patient is instructed to feel the ob- this point. Examiner: “Would you like to take
ject with one hand and to take as much time another break now?”
as needed. If the patient cannot name the ob-
ject, he/she is asked to describe for what pur- Part 3
pose the object is used. The patient starts with
the dominant hand. Five trials are conducted Posture and gait assessment
for each hand. Objects are placed between These assessments are completed first with the
thumb and index fingers for patients, with patient seated, then standing up, and finally walk-
 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 197

ing. The examinations are most conveniently com- after first instructing the patient to stand with
pleted as a unit before scores are entered. If the arms by sides. [Test for echopraxia.]
examiner is unfamiliar with the assessment, the Biock C (12) The patient is asked to balance
examination could be divided into three smaller himself for 15 s on each leg in turn. (13) The pa-
subunits (see below), each to be carried out as a tient is instructed to walk a few steps, stop, and
block. It is important, however, that ratings for return [observe gait, etc.]. (14) Tandem walking
global items such as dyskinetic movements be [see item description].
entered after the examiner has observed the patient l Gait (exaggerated associated movement): Ex-
perform in all three blocks. The recommended se- cess arm, leg, or trunk movement observed
quence of examination is divided into Blocks A, B, during walking.
and C. 0 - Absent
1 - Definitely present
Block A: (1) The patient has been observed dur-
2 - Markedly or pervasively present
ing the preceding parts of the assessment for global
items such as perseveration, echopraxia, and l Gait (reduced associated movement): Reduced
mutism. (2) The patient is seated in a chair with arm, leg, or trunk movement observed during
walking.
his/her hands on knees, with legs slightly apart,
and with feet flat on the floor. [Observe involun- 0 - Absent
tary movement in the entire body.] (3) The patient 1 - Definitely present
is asked to sit with his/her hands hanging unsup- 2 - Markedly or pervasively present
ported (if the patient is male, with hands between l Slow/shuffrig gait: Typical parkinsonian gait
legs; if the patient is a female, with hands hanging rated.
over knees). [Observe involuntary movements in 0 - Absent
1 - Definitely present
hands and body.] (4) The patient is asked to open
2 - Markedly or pervasively present
his/her mouth. [Observe involuntary tongue move-
l Manneristic/bizarre gait: Mere clumsy or
ment.] (5) The patient is asked to protrude tongue.
lumbering gaits should not be rated, and gait
[Observe involuntary movement.] (6) The patient
should be idiosyncratic rather than haunched,
is asked to tap thumb with each finger as rapidly
lordotic, or shuffling - for example, con-
as possible for about 15 s, first with the left and
strained, mincing, overprecise; or alternative-
then the right hand. [Observe involuntary move-
ly extravagant, overelaborate, featuring
ments of face and legs.],
interpolated movements such as sidesteps and
Block B: (7) The patient is asked to stand up. bowing. Also bizarre crablike, crouching, or
[Observe posture.] (8) The patient is asked to hold anthropoid gaits, and those with multiple, not
extended arms horizontally in front and then to easily described abnormalities.
have the eyes closed. [Observe pronator drift, 0 - Absent
tremor, and Romberg’s sign.] Then the extended 1 - Definitely present
arms are moved to the side, and instruction is 2 - Markedly or pervasively present
given, with demonstration, to drop the arms to the l Dyskinetic face and head movement: Simple
sides of the body. [Observe arm dropping and im- brief/dyskinesia-like, including chorea. Do
posed posture.] (9) The examiner instructs the pa- not rate tongue movements unless they also
tient to let the arms go loose and then moves the involve the mouth or the jaw.
patient’s arms into various positions, at times re- 0 - Absent
leasing support and noting whether the arms drop 1 - Definitely present
freely (imposed posture and gegenhalten). (10) The 2 - Markedly or pervasively present
examiner raises each of the patient’s outstretched 8 Sustained face and head movement: Simple
arms in turn with one finger after instructing the sustained/grimace-like. Do not rate tongue
patient to resist this. [Test for mitgehen.] (II) The movements unless they also involve the
examiner pats the sides of his own legs, then taps mouth or the jaw (e.g., spasmodic facial con-
his own chest, and then scratches his own head tortions); should not be completely fixed.
198 Eric Y.H. Chen et al. /Psychiatry Research 56 (199s) 183-204

l Complex face and head mannerism/stereotypy: brief/dyskinesia-like (e.g., stamping move-

Complex mannerismstereotypy-like (usually ments of legs, rocking trunk movements).
of head; e.g., turning away, side-to-side looks, Specify: random/irregularly repetitiveirhyth-
searching movements). mical/tic-like; including rocking and chorea.
l Gegenhalten: Resistance to passive movement l Dystonic trunk/limb movement: For example,
which increases with the force exerted. dystonic posturing of extremities, hyper-
Typically has a “springy” quality and appears pronation on arm raising, torsion movements.
automatic rather than willful. May be l Trunk/limb mannerism/stereotypy: More
restricted to just one muscle group. Resis- stereotypy-like - for example, rubbing the
tance increases with increasing force. thumb over the forefinger; other kinds of
l Mitgehen: “Anglepoise lamp” raising of arm finger play; touching, rubbing, stroking, and
in response to light pressure, in the presence patting various parts of the body, especially
of an apparent grasp of the need to resist; the face. Also repeatedly turning the head
should be demonstrable repeatedly. Severity away from the examiner, looking round
of rating depends on the rapidity and appar- distractedly throughout the interview, twist-
ent wish to anticipate the movement. Do not ing one arm up behind the back while walk-
rate if understanding of instruction is poor. ing, and repeatedly rising from chair to ap-
l Simple abnormal posture: Posture while proach the examiner. More mannerism-
standing. like - for example, holding arms in an unnat-
0 - Normal zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ural crooked way, holding an arm out in a
1 - Somewhat stooped meaningless gesture, and keeping one arm
2 -Very stooped with downward gaze or rigid tucked under armpit.
and extended l Arm drift: Patient asked to hold two arms
l Complex abnormalposture: Mere ungainliness straight in front of him/her horizontally and
or slouching should not be rated. close the eye. Downward drift of one or both
0 - Normal of the arms is observed. (Examiner: “Could
1 - Assuming, for example, obviously abnormal you hold your arms out in front of you, like
hunched, constrained “closed” or alternatively ex- this [demonstrate]. Now close your eyes and
aggeratedly slack, overrelaxed positions when sit- keep the arms in the same place.“)
ting; hugging sides, twisting legs round each other, l Arm dropping: The patient and the examiner
sitting with torso forward but legs to one side in both raise their arms to shoulder height and
extremely uncomfortable way. let them fall to their sides. In a normal sub-
2 - Marked or pervasive posturing. For example: ject, a stout slap is heard, and there is a slight,
while sitting, repeatedly hunching forward and natural rebound as the arms hit the sides. If
rocking; while standing or walking, striking a suc- the sign is positive, the arms fall very slowly.
cession of poses. (Examiner: “Now relax and let the arms drop
l Persistence of imposed postures: This is tested to the sides like this [demonstrate].“)
while testing tone of upper limb. If abnor- 0 - Normal, free fall with loud slap and rebound
mality is suspected, further testing is carried 1 - Fall slowed with less audible contact and little
out, positioning the patient’s limbs and releas- rebound
ing them. 2 -Arms fall as though against resistance; as
0 - Normal though through glue
1 -Not sustained: tendency to retain limb posi- l Tremor (postural): Rated with patient’s arms
tions passively imposed during testing for at least outstretched. Typical resting, low frequency,
several seconds; this should be observed more than parkinsonian “pill-rolling” tremor rated.
once. 0 - No tremor
2 - Sustained “waxy flexibility” 1 - Mild or occasional tremor
l Dyskinetic trunk/limb movement: Simple 2 - Gross or persistent tremor
 Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 199

l Tremor (resting): Rated with patient’s arms l Neck rigidity: Range of neck movement is
by the side. Typical resting, low-frequency, gently tested with patient seated, after ex-
parkinsonian “pill-rolling” tremor rated. planation.
0 - No tremor 0 - Absent
1 - Mild or occasional tremor 1 - Definitely present
2 - Gross or persistent tremor 2 - Markedly or pervasively present
8 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Romberg ‘s sign: Standing with eyes closed and l Overactivity: [Do not rate simple restlessness/
feet together. akasthisia; do not rate unless substantial.]
0 - Normally still or slight weaving Typically bizarre rather than resembling sim-
1 - Widened base to stay in place ple restlessness; akathisia should be excluded
2 - Unable to stand still with eyes closed where suspected.
l Balance on one leg: Stand on one leg with eyes 0 - Absent
open for 10 s. 1 -Continual motor unrest: e.g., crossing and
0 - No difficulty uncrossing legs, looking around, half rising from
1 - With great difficulty the chair; executing unending series of manneristic
2 - Unable to perform actions, touching body, then clasping hands, then
Rate irrespective of side gripping the chair arm, etc.
l Walking: Walking down the hall at least five 2 - Approaching catatonic excitement: in more
paces. Other abnormalities not previously or less constant motion, incessantly performing
rated: e.g., spastic, hemiplegic gait. pointless actions, which are reiterated, elaborated,
l Tandem walking: Heel to toe for 10 paces. and transformed into one another: e.g., touching
l Abrupt/rapid spontaneous movement: For ex- cardigan, then moving hands up and down the
ample, sudden gestures, acts carried out edges, then unbuttoning cardigan and buttoning it
smartly, springs to attention when asked to up again, followed by breaking off interview to
stand. clamber over the tables and chairs on the ward.
8 Slow/feeble spontaneous movement: Weak, Also full-blown excitement: e.g., patient who
languid, labored movements moved round and round the ward, striking an
l Exaggerated movements: Accompanied by endless series of quasi-symbolic poses.
flourishes/flurries of adventitious movements l Underactivity: [Do not rate if the patient is
l Iterations of spontaneous movements: Gestures clearly sedated/parkinsonian; do not rate
or mannerisms repeated over short space of unless substantial.] Some degree of abnor-
time: e.g., touching face and then repeating mality is commonly observed and should not
this several times; manneristically smoothing be rated unless very noticeable.
hair, then repeating this with increasing force 0 - Absent
until striking head; touching ring finger on 1 - Sits abnormally still throughout the interview
one hand (while alluding to ring being stolen), with hardly any postural shifts; slumped in chair;
then doing the same on the other hand, then very passive.
repeating the whole sequence. 2 - Marked hypokinesia, generally with striking
0 .dmbitendence: For example, extending arm absence of postural adjustments: e.g., sitting
when examiner’s arm is proffered; halting in perched on chair in same position throughout in-
mid-action and moving arm to one side; while terview, not turning head when addressed from
walking, stopping, half-turning back, and different direction; always sitting in same place on
then continuing. ward with arms in praying position. Also full-
l Mutism: Global rating for entire interview. blown stupor if encountered.
0 - No mutism l Automatic obedience: May take the form of
1 - Fewer than 10 isolated words in whole in- exaggerated cooperation with instructed
terview movements: e.g., when asked to lift a finger,
2 - No speech whole arm raised; when arm reached for,
200 Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

whole body leant forward and turned toward the floor, which are reached for and scrutinized;
examiner; holding out both hands when randomly approaching various objects, including
examiner’s hand is offered for shaking. Alter- wastebasket, rummaging in it, extracting apple
natively, spontaneous continuation of ac- core, and eating it.
tions: e.g., flapping arms when asked to drop 0 - Absent
them to sides; actively continuing passive arm 1 - Definitely present
movements during examination for tone. Oc- 2 - Markedly or pervasively present
casionally, complying with all requests to an l Echophenomena: Tendency to repeat the
extraordinary degree: e.g., patient who screw- examiner’s speech or mimic the examiner’s ac-
ed up eyes when asked to close them; peered tion. Echopraxia: incomplete copying move-
intently in caricatured way when asked to ments should not be rated, and exercise
look out of window; when asked to keep head judgment as to whether patient is just trying
up while walking, proceeded across the room to be helpful. As well as being merely copied,
with neck hyperextended. movements may be modified or amplified:
l Poor/feeble compliance: Inability to perform e.g., smoothing of hair substituted for exam-
requested actions not explained by poor iner’s scratching of head, echopraxic chest
understanding, general uncooperativeness, patting progressively exaggerated until pa-
blocking/ambitendence, or parkinsonism; tient pulling at his shirt. Global rating for
often has a bizarre quality - e.g., when rais- echophenomena
ing arm, movement gradually dies away; car- l Perseveration: Tendency to persist in a partic-
ries out most instructions promptly but fails ular response after it ceased to be appropri-
to comply with some; cannot seem to main- ate. Global rating for perseveration
tain arms outstretched; when asked to hold [End of examination]
out arms, only seems able to do so in
halfhearted, crooked way; when asked to
raise a linger, after some delay lifts thumb. Neurological soft signs assessment score sheet
l Other abnormal behavior: Specify negativism/
hypermetamorphosis. Do not rate any other Patient:
abnormality than these. Number:
Negativism: Should always reflect concrete in- Rater:
stances rather than indefinite attitude - e.g., pull- Date:
ing arm violently away whenever the examiner Instruction: Enter rating in scoring sheet within
reaches for it, holding breath when asked to [ ] space provided. Enter additional remarks in the
breathe deeply, shutting eyes tightly when ap- following space [ 1. Unless otherwise specified, rate
proached with an ophthalmoscope, or jumping up as follows:
when asked to lie down. Also, taking off socks 0 - Normal
when told to put shoes on; getting up from cus- 0.5 - Subthreshold
tomary reclining position and walking away when- 1 - Definitely abnormal
ever approached by examiner. Occasionally, 2 - Grossly abnormal
domination of entire behavior by bizarre con- 9 -Missing. Or unable to test, lack of coopera-
trariness: e.g., normally quiet patient who met at- tion or comprehension
tempts to examine him with immediate struggling Additional description can be entered next to
and vilification; leant backwards when pulled for- rating in the space provided. Additional informa-
wards; refused to stand up and then refused to sit tion is advisable if a rating of “0.5” or “9” is se-
down again. lected. Do not use rating “2” if a test can only be
Hypermetamorphosis: Typically only seen in either positive or negative; such dichotomous
setting of marked overactivity - e.g., attention items (e.g., extensor plantar response) are in-
repeatedly drawn by specks, bits of fluff, etc., on dicated in the item description.
Eric Y. H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 201

Part 1 Score sheet

Articulation [ 1 1
Aprosodic I 1 I i
Unintelligible 1 I
Extent of smooth
pursuit eye movements
I 1 I 1

Smoothness of smooth I 1 ! 1
pursuit eye movements
Impersistent gaze
Saccade smoothness
I 1 I
Saccade blink suppression
Saccade head movements
[ 1 I i1
Wink
Glabellar tap
1 1I 1
tI zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONML
1
1

Rapid tongue movements I 1 I 1

lmpersistent tongue protrusion 1 1 1 1
Extensor plantar reflex (left)
Extensor plantar reflex (right) I 1I 1
Tone Strength Reflex

Upper limb Left N/A Left

increased Right Right
Upper limb Left Left Left
decreased Right Right Right
Lower limb Left N/A Left
increased Right Right Right
Lower limb Left Left Left
decreased Right Right Right
202 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

Part 2 Score sheet

Snout reflex 1 1
Grasp reflex I
Palmomental reflex [ I I 1

Laterality of palmomental reflex

Hand Stimulated
Left Right
Chin response Left
Right

Finger-nose test (left)

Finger-nose test (right)
Finger-thumb tapping (left) [
Finger-thumb tapping (right) [
Finger-thumb opposition [
(left)
Finger-thumb opposition [
b-k&t)
Mirror movements (left) [
Mirror movements (right) [
Diadochokinesia (left)
Diadochokinesia (right) I
Mirror movements (left) [
Mirror movements (right)
Fist-edge-palm test (left) I
Fist-edge-palm test (right) [
Oseretsky test (left) I
Oseretsky test (right) [

Rhythm tapping test [ ] [ ]

Stimulus sequence Response

I z * * l * l

2 . + . l * l

3 *.. *. , l ..
4 l. . . * l

5 . . * . . *
 Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204 203

Go/no-go test 1 1 [ 1

Stimulus * * * * 1 * *
Response

Extinction I 1 1 1

Stimulus Right cheek Left cheek Right cheek Left cheek Right hand Right cheek
Stimulus Left hand Right hand Right hand Left hand Left hand Left cheek
Response

Finger agnosia (left) 1 I 1

Finger agnosia (right) 1 I I

Left-hand response 2-4 1-3 3-4 2-5 1-5

Right-hand response l-3 2-4 1-4 2-3 l-5

Stereognosia (left) 1 [ I
Stereognosia (right) I I I I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQ

Graphesthesia (left) 1 I[ I
Graphesthesia (right) I I I I

Left-hand response 3 I 8 5 9
Right-hand response 2 4 0 3 6

Left-right orientation [ I 1 I

Point to Your right Your left Your left Your right My left My right My left My right
foot hand shoulder ear knee elbow hand hand
With Your right Your left Your right Your left
hand hand hand hand
204 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Eric Y.H. Chen et al. /Psychiatry Research 56 (1995) 183- 204

Part 3 Score sheet

Gait - increased movement

Gait - decreased movement
Gait - shuBling
Gait - manneristic
Facial dyskinesia
Face, head movement -
sustained
Face, head movement,
complex/stereotypy
Gegenhalten
Mitgehen
Simple abnormal posture
Complex abnormal posture
Imposed posture persistence
Trunk-limb dyskinesia
Trunk-limb dystonia
Trunk-limb mannerism
Standing
Arm drift
Arm dropping
Tremor (postural)
Tremor (resting)
Romberg’s sign
Balance (left)
Balance (right)
Walking
Tandem walking
Abrupt spontaneous move-
ment
Slow spontaneous movement
Exaggerated movements
Iterative spontaneous move-
ments
Ambitendency
Mutism
Neck rigidity
Overactivity
Underactivity
Automatic obedience
Noncompliance
Other abnormal behavior
Echophenomena
Perseveration