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Essential tremor (ET) is typically 4 to 12 Hz frequency, absent at rest, maximal during maintenance of a posture, attenuated during movement and often accentuated at the termination of movement. Prevalence in Americans is 300 to 415 per 100,000 population, and it is frequently disabling. There is controversy about the central or peripheral origin of ET. There is no specific diagnostic test for ET; the diagnosis is made clinically. Ethanol is the most effective suppressor of ET. Treatment is with beta-adrenergic blockers, primidone, and benzodiazepines. The first systematic description of essential tremor (ET) was 100 years ago by Dana in 1887, who regarded the disorder as a hereditary tremor that was a form of "motor neurosis." Most subsequent contributions to the English literature consisted predominantly of case reports until Critchley's exhaustive survey of the subject in 1949. The disorder has been variously termed essential, benign essential, hereditary, familial, idiopathic, juvenile, presenile or senile tremor.

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Drug-induced antiphospholipid antibodies have been considered insignificant, a belief that has recently been questioned. Previous studies noted an association between chlorpromazine treatment and the presence of anticardiolipin antibodies (ACA), especially IgM ACA, and have suggested that thrombosis might be more likely in the presence of IgG ACA. We studied the cases of 27 patients receiving long-term neuroleptic therapy who had no history of cerebrovascular disease. IgG ACA was present in 7 (26%) of the 27, and IgM ACA was present in 5 (19%), yet none had shown any manifestations of cerebrovascular disease since initiation of neuroleptic therapy. These data suggest that drug-induced ACA do not predispose to cerebrovascular disease, even when IgG ACA is predominant.

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We investigated the tremolytic effect of long-acting propranolol (propranolol-LA) in six subjects with drug-induced parkinsonism (DIP), using a double-blind, placebo-controlled, crossover experimental design. Subjects received propranolol-LA for 2 weeks and placebo for 2 weeks, with no change in neuroleptic treatment. Tremor frequency and amplitude were objectively quantified at the end of each 2-week period by computerized tremorgram recording. There were no significant differences in attenuation of DIP tremor by propranolol-LA and placebo. Previous investigations reported in the literature have found propranolol to attenuate the tremor of idiopathic parkinsonism (IPD). It is expected that DIP and IPD tremor would respond similarly to propranolol if a solely peripheral or spinal cord tremolytic action were operative. A possible differential attenuation of IPD tremor and DIP tremor provides support for the concept of a higher central tremolytic mechanism of beta-adrenergic receptor-blocking drugs.

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Comprehensive speech examinations of 10 equally affected subjects with moderate, treated Parkinson's disease were performed before and 4 weeks following initiation of treatment with selegiline (deprenyl), with other drug therapies unchanged. Forty different measures relating to the speech processes of respiration, phonation, resonation, articulation and prosody were examined to measure changes in performance due to selegiline. Significant improvements were noted for 8 of the 40 measures, with these improvements relating to the speech processes of articulation and respiration. The potential interactive effects of comedication are discussed. In addition, previously undescribed comprehensive speech characteristics of moderate Parkinson's disease are presented and discussed.

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Dystonias can be classified by etiology (idiopathic or symptomatic), by age of onset (childhood, adolescence or adult), and by anatomical involvement (focal, segmental or generalized). Cervical dystonia (torticollis) is one of the most common focal dystonias. We describe our experience in the treatment of 15 consecutive cervical dystonia patients by chemodenervation with botulinum A toxin (BOTOX), with significant improvement being objectively measured. Botox is accepted as a safe and efficacious modality for the treatment of cervical dystonia.

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Essential tremor (ET), more common than Parkinson's disease (PD), has commonly been considered "benign." This investigation compared diagnostic characteristics, patient satisfaction with treatment, and psychosocial complications between a group of male patients treated for essential tremor and a group of male parkinsonian patients. Those who had ET tended to be more commonly misdiagnosed than those with PD. Fewer ET patients were satisfied with response to treatment than PD patients. Both groups equally expressed embarrassment about their condition, and both perceived similar difficulties with common activities of daily living and social situations. There were no significant differences between ET and PD patients for history of ethanol use or pharmacotherapy for anxiety or depression.

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Abdominal pain caused by diabetic radiculopathy is uncommon, and abdominal hernia as a complication is rare. We report a case of abdominal wall herniation caused by diabetic truncal radiculopathy requiring surgical repair. Clinical and diagnostic features of this entity are reviewed.

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When dealing with movement disorders, it is helpful to first decide what phenomenon one is observing. Tremors can be differentiated from most other movement disorders and are further classified according to their frequency, and whether they are present at rest or with action. The parkinsonian syndrome can thus be identified correctly in most cases, and the etiology can usually be determined clinically. Correct diagnosis is the first step in correct treatment.

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Trigeminal neuralgia is most commonly idiopathic, although it can be associated with multiple sclerosis. Tumors are rare causes of trigeminal neuralgia. A case is presented of trigeminal neuralgia with normal neurological examination and responsive to carbamazepine, secondary to a cerebellopontine angle meningioma. Literature relative to neoplastic etiologies of trigeminal neuralgia is reviewed. The role of electrodiagnostic testing in the evaluation of trigeminal neuralgia is considered. A normal neurological examination and responsiveness to carbamazepine do not exclude tumor as an etiology of trigeminal neuralgia.

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Fifty-three male, Caucasian, neuroleptic-treated patients with chronic schizophrenia were examined for the presence of tardive dyskinesia (TD) and were tissue typed. The group with TD (n = 25) was compared to the group without TD (n = 28). HLA-DR4 was more prevalent in the group with TD than in the group without TD, with a relative risk of 3.04 for TD with HLA-DR4 present, although this finding is not statistically significant when corrected for the number of nonparametric comparisons. Other investigations reported an association between HLA-B44 and TD, or between HLA-B44 and neuroleptic-induced parkinsonism. Potential explanations relating the findings of these investigations are discussed.

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The urine samples from two groups of Veteran's Administration patients newly admitted to general psychiatry units were screened in 1985 and in 1987-88 for abused drugs. The results were compared with urine samples from controls with similar age distributions admitted to an alcohol and drug abuse unit or to medical-surgical units. About 40% of all newly admitted patients were positive for one or more controlled drugs, but there were no significant differences among patient groups in the percentage of urine samples positive for these drugs. Marijuana and benzodiazepines were detected frequently in all patient groups and often in combination, although opiates also were frequently detected in the urine samples from the medical-surgical patients. There was a clear decrease in drug-positive samples with age in all patient groups, much of which could be accounted for by decreased marijuana detection.

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We report two cases of cranial dystonia (blepharospasm) associated with olivopontocerebellar atrophy (OPCA). The pathophysiology of blepharospasm appears to involve an increased excitability of the interneurons of the blink and corneal reflexes. It is hypothesized that blepharospasm associated with OPCA might be due to rostral brainstem lesions disrupting central dopaminergic and cholinergic pathways, resulting in disinhibition of brainstem reflexes or denervation supersensitivity of the facial nuclear complex.

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STUDY OBJECTIVE: To determine whether patients with Parkinson disease are at an increased risk for postoperative confusion. DESIGN: Retrospective chart review of patients with Parkinson disease who remained in the hospital at least 48 hours after their surgery. Current data were compared with published historical controls. SETTING: Recent medical records of a university-affiliated hospital, Veterans Administration hospital, and community hospital. PATIENTS: Available charts of patients with Parkinson disease who had had surgery in the last 2 years. Patients were excluded if they were disoriented at admission or had serious metabolic disturbances. MEASUREMENTS AND MAIN RESULTS: Fifteen of twenty-five postoperative patients with Parkinson disease (60%; CI, 39% to 78%) suffered significant acute confusion, and 9 of these patients had documented hallucinations. Neuropsychiatric changes were frequently delayed after surgery. The acute confusional state lasted an average 2.5 days; several patients, however, were discharged before resolution. These disturbances did not appear to be related to type of anti-parkinsonian medication or anesthetic. CONCLUSION: In comparison with historical controls, the relative risk of patients with Parkinson disease having an acute postoperative confusional state is between 2.8 and 8.1. These patients may need environmental supports during the postoperative period.

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In a crossover experiment the authors investigated the effects of repeated weekly, 2-day, haloperidol drug holidays on serum haloperidol concentrations, mental status, and neuroleptic-induced movement disorders in seven chronic schizophrenic patients. Haloperidol concentrations decreased about 64% during the initial 36 hours of drug holiday and subsequently increased slightly during the next 24 hours of drug holiday. Two-day weekly drug holidays for 6 weeks resulted in an average reduction of 25% in serum haloperidol concentrations at all drug holiday points. Mental status and movement disorders scores, rated by observers blind to the drug-holiday condition, were not significantly affected by drug holidays.

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The results of two epidemiological studies suggest a hereditary predisposition to develop drug-induced parkinsonism. We investigated human leukocyte antigen (HLA) antigen prevalence rates in patients with neuroleptic-induced parkinsonism. Fifty-two male, white, neuroleptic-treated, chronic in-patients with DSM-III-diagnosed schizophrenia were examined for the presence of parkinsonism. Subjects were tested for 23 type A, 43 type B, 4 type C, and 10 type DR HLA antigens. The group of schizophrenic patients with parkinsonism (n = 29) was compared with the group of schizophrenic patients without parkinsonism (n = 23). There were no significant differences between the two groups with respect to age, duration of neuroleptic exposure, or anticholinergic drug exposure. One HLA antigen, B44, was significantly more prevalent in the group with parkinsonism than in the group without parkinsonism. We derived a relative risk of 7.16 for drug-induced parkinsonism with HLA-B44 present in this group of schizophrenic patients. These data indicate that HLA-B44 may play a role in genetic or immunologic susceptibility to develop drug-induced parkinsonism in white schizophrenic individuals.

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The anterior temporal cerebral region is not well covered, electroencephalographically, by the usual EEG electrodes. Numerous attempts have been made to add anterior temporal electrodes. There has been discussion regarding the amount of additional information actually attributable to those electrodes. We systematically evaluated the abnormalities revealed by one such noninvasive set of anterior temporal electrodes, D. Silverman's T1 and T2. A total of 624 consecutive EEGs were reviewed. We conclude that, in the adult, anterior temporal electrodes can add significantly to the information contained in the routine interictal EEG.

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