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Balance and Gait Deficits in Schizophrenia Compounded by the Comorbidity of Alcoholism

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Balance and Gait Deficits in Schizophrenia Compounded by the Comorbidity of Alcoholism BRIEF REPORTS 15 states after zolpidem and placebo: a H2 O-PET study. J Sleep hashi K: Activity of midbrain reticular formation and neocortex Res 2000; 9:161–173 during the progression of human non-rapid eye movement 4. Kajimura N, Kato M, Okuma T, Sekimoto M, Watanabe T, Taka- sleep. J Neurosci 1999; 19:10065–10073 hashi K: A quantitative sleep EEG study on the effects of benzo- 9. Talairach J, Tournoux P: Co-Planar Stereotaxic Atlas of the Hu- diazepine and zopiclone in schizophrenic patients. Schizophr man Brain: Three-Dimensional Proportional System. Stuttgart, Res 1995; 15:303–312 Germany, Georg Thieme, 1988 5. Rechtschaffen A, Kales A (eds): A Manual of Standardized Ter- 10. Sakai F, Mansari M, Jin JS, Zhang JG, Vanni-Mercier G: Posterior minology, Techniques and Scoring System for Sleep Stages of hypothalamus in the regulation of wakefulness and paradoxi- Human Subjects: NIH Publication 204. Bethesda, Md, Public cal sleep, in The Diencephalon and Sleep. Edited by Mancia M, Health Service, National Institutes of Health, 1968 Marini G. New York, Raven Press, 1990, pp 171–198 6. Herscovitch P, Markham J, Raichle ME: Brain blood flow mea- 11. Koyama Y, Hayaishi O: Firing of neurons in the preoptic/ante- 15 sured with intravenous H2 O, I: theory and error analysis. J rior hypothalamic areas in rat: its possible involvement in slow Nucl Med 1983; 24:782–789 wave sleep and paradoxical sleep. Neurosci Res 1994; 19:31– 7. Raichle ME, Martin WRW, Herscovitch P, Mintum MA, Makkam 38 15 J: Brain blood flow measured with intravenous H2 O, II: imple- 12. Veselis RA, Reinsel RA, Beattie BJ, Mawlawi OR, Feshchenko VA, mentation and validation. J Nucl Med 1983; 24:790–798 DiResta GR, Larson SM, Blasberg RG: Midazolam changes cere- 15 8. Kajimura N, Uchiyama M, Takayama Y, Uchida S, Uema T, Kato bral blood flow in discrete brain regions: an H2 O positron M, Sekimoto M, Watanabe T, Nakajima T, Horikoshi S, Ogawa K, emission tomography study. Anesthesiology 1997; 87:1106– Nishikawa M, Hiroki M, Kudo Y, Matsuda H, Okawa M, Taka- 1117 Brief Report Balance and Gait Deficits in Schizophrenia Compounded by the Comorbidity of Alcoholism Edith V. Sullivan, Ph.D. nonschizophrenic patients with alcohol dependence, and 27 age-matched comparison men. Margaret J. Rosenbloom, M.A. Results: All three patient groups were impaired relative to the Adolf Pfefferbaum, M.D. comparison subjects. The comorbid group was significantly more impaired than the alcoholic group on most tests and was more impaired than the schizophrenia patients, especially Objective: Alcoholism carries a liability of balance and gait in- when tested with eyes open. stability that persists with sobriety. Such deficits are less well documented in schizophrenia and may be compounded by co- Conclusions: Rigorous quantitative testing revealed gait and morbidity with alcoholism, which is prevalent in schizophrenia. balance deficits in schizophrenia, even without alcohol depen- dence, and exacerbated deficits in schizophrenia comorbid with Method: The authors administered quantitative ataxia tests to alcoholism. The enhancement of postural stability expected 10 patients comorbid for schizophrenia and alcohol depen- with visual information was dampened in comorbid patients, dence/abuse, 10 nonalcoholic patients with schizophrenia, 24 implicating compromised sensorimotor integrative abilities. (Am J Psychiatry 2004; 161:751–755) Disequilibrium and gait peculiarities were featured in erbates existing deficits of brain volume in prefrontal and classic descriptions (1, 2) of patients with schizophrenia, anterior temporal gray matter (16) and produces deficits in even before the advent of neuroleptics, and are detectable the anterior superior cerebellar vermis (17) and pons (18), with clinical neurological assessment (3–5). Ataxia of even in schizophrenia patients with remote histories of al- stance and gait is also salient behavioral sequelae to coholism and low levels of lifetime alcohol consumption chronic alcohol abuse (4, 6, 7) and may arise from com- relative to alcoholic patients without schizophrenia. Given promise of the anterior superior cerebellar vermis (post- this heightened vulnerability for patients comorbid for mortem [6, 8, 9] and in vivo [10]). both schizophrenia and alcoholism, especially in the an- Comorbidity of ataxia with alcohol use disorders is highly terior superior cerebellar vermis, we assessed gait and prevalent in schizophrenia (e.g., references 11, 12, 13) and balance by using quantitative ataxia tests to determine has an adverse impact on schizophrenia’s clinical course whether comorbid patients would show greater postural in- (for reviews, see references 14, 15). Such comorbidity exac- stability than patients with either condition alone. Am J Psychiatry 161:4, April 2004 http://ajp.psychiatryonline.org 751 BRIEF REPORTS TABLE 1. Demographic and Clinical Characteristics of Healthy Comparison Subjects, Patients With Alcoholism Only, Patients With Schizophrenia Only, and Patients With Both Disorders Brief Psychiatric Education Handedness Lifetime Alcohol Rating Scale Age (years) IQa (years) Testb Intake (kg)c Score Group Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Healthy comparison subjects (N=27) 47.9 11.6 113.2 7.2 17.1 2.6 23.7 13.1 52.8 86.1 — Patients with alcoholism (N=24) 49.1 11.1 107.0 8.3 13.6 3.2 24.6 14.9 1288.1 797.3 — Patients with schizophrenia (N=10) 42.9 10.3 109.1 9.7 14.3 1.9 19.3 12.3 35.4 33.1 37.8 10.9 Patients with comorbid schizophre- nia and alcoholism (N=10) 45.3 4.5 104.9 8.1 13.9 1.5 24.6 14.9 126.4 140.6 39.1 8.9 a Based on the National Adult Reading Test. b Right-handedness=14–30; left-handedness=50–70 (Crovitz and Zener [27]). c Quantitative alcohol use data were available for nine patients with schizophrenia and nine patients with comorbid schizophrenia and alcoholism. Method tients with schizophrenia (t=1.89, df=16, p<0.10). The three patient groups had equivalent years of education and National Adult All subjects were men and gave written informed consent to Reading Test IQs. The comorbid group did not differ significantly participate in the research. The patients were recruited from a from the schizophrenia group in BPRS scores. Veterans Administration medical center and included 10 with a Gait and static balance were assessed with the Walk-a-Line DSM-III-R axis I diagnosis of schizophrenia only, 10 comorbid for Ataxia Battery (28), consisting of three parts, each performed first DSM-III-R-defined schizophrenia and alcohol dependence or with eyes open and then with eyes closed. First, the subject stood abuse, and 24 with DSM-III-R-defined alcohol dependence only. with feet placed heel to toe and arms folded across the chest for No patient met criteria for any other axis I disorder, with the ex- 60-second trials (“stand heel to toe”). Next, the subject stood on ception of two of the comorbid patients who had a history of past one foot for 30-second trials (“stand on one foot”). Finally, the cannabis abuse. subject walked heel to toe for 10 steps (“walk heel to toe”). Each The patients with schizophrenia were tested for gait and bal- condition was performed twice unless the subject achieved a per- ance while inpatients; the patients with alcoholism were tested fect score on the initial trial. when returning for follow-up studies (19, 20). Alcoholic patients Because gait and balance performance can decline with age, reported a wide range of days of sobriety (1 to 1,994, median=204) we applied linear regression to data from the larger group of at the time of testing. The comorbid patients also reported a wide healthy comparison subjects spanning the adult age range (20 to range of days of sobriety (17 to 3,285, median=88). The length of 70 years) to derive age-corrected standardized z scores for each sobriety did not differ between these groups (Mann-Whitney U= participant (10). Values for each group reflect the extent to which 117, df=32, p=0.91). it deviated from age norms. Group differences in performance for All schizophrenia patients had been treated pharmacologi- each composite were assessed with four-group, one- or two-way cally; when tested, five schizophrenia and seven comorbid pa- ANOVAs and follow-up Scheffé tests. Associations between vari- tients were taking atypical antipsychotic medications, three ables were assessed with Pearson’s correlations and confirmed schizophrenic and two comorbid patients were taking typical an- with Spearman’s tests because of small group sizes. tipsychotic medications, one schizophrenic patient was tempo- rarily unmedicated, and the medication status was unknown for Results one schizophrenic and one comorbid patient. Current symptom severity was evaluated in patients with schizophrenia by using Composite scores for the eyes-open and eyes-closed the Brief Psychiatric Rating Scale (BPRS) (21), administered by conditions (Figure 1) showed significant effects of group two raters with established reliability. Lifetime alcohol consump- (F=15.97, df=3, 65, p=0.0001) and condition (F=13.24, df= tion was assessed by using a semistructured interview (22–25) in all patients with alcoholism and healthy comparison subjects, 1, 65, p=0.0005); the interaction (F=6.41, df=3, 65, p= nine of the 10 comorbid patients, and nine of the 10 patients with 0.0007) indicated greater deficits in all three patient schizophrenia only. groups with eyes open than with eyes closed. With one ex- The healthy comparison group was recruited from the local ception (alcoholics with eyes closed), follow-up tests community and comprised 27 men selected from a larger group showed that all patient groups had deficits in both condi- of 61 men (e.g., reference 10) to age-match the patient groups.
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