Vol. 6, No.
1, April 2003
FORENSIC DO CUME NT EXAMINATION/Handwriting and Schizophrenia: 40-3-030306/0304
HANDWRITING IN SCHIZOPHRENIA
A kinematic analysis of handwriting movements.
by Oliver Tucha1, Geraldine M. Paul1, Lara Mecklinger1,
Peter Eichhammer2, Helmfried K. Klein2, and Klaus W. Lange1
REFERENCES:, Tucha, O., Paul, G. M., Mecklinger, L., Eichhammer,
P., Klein, H. K., and Lange, K. W., "Handwriting In Schizophrenia,"
The International Journal of Forensic Document Examiners, Vol. 6, No.
1, April 2003, pp. 1-3.
ABSTRACT: Patients with schizophrenia display a psychomotor poverty
characterized by a slowing of both motor and mental activities. Most
previous studies have assessed motor functioning in schizophrenia by
examining patients on neuroleptic treatment. In the present study, a
kinematic analysis of automated handwriting movements of 12 inpatients
with untreated schizophrenia was performed using a digitizing tablet. In
comparison to a healthy control group, patients with untreated
schizophrenia displayed an increased movement time. Furthermore, the
patients showed a reduced automation of handwriting, manifesting itself
in an increased number of inversions of both velocity and acceleration
profiles.
KEYWORDS: Handwriting, psychomotor, schizophrenia.
INTRODUCTIONS
A slowing of motor and mental activities can be observed in
neuropsychiatric disorders such as schizophrenia, Parkinson’s disease and
depression [1], which has been described respectively as psychomotor
poverty, bradykinesia and psychomotor retardation, respectively. This
psychomotor slowing is regarded by some authors to be the manifestation
of a general syndrome underlying several psychiatric and neurological
diseases [2, 1]. Since most studies have assessed motor functioning in
schizophrenia by examining patients under treatment with classical
neuroleptic compounds, motor dysfunction in these patients may be the
result of motor side-effects of neuroleptic medication.
The pharmacological treatment of schizophrenia with classical
neuroleptics is associated with a number of adverse side-effects. Acute
extrapyramidal symptoms such as akathisia, parkinsonism and dystonia are
common in schizophrenic patients treated with neuroleptics. Furthermore,
tardive dyskinesia, a syndrome of involuntary movements with late onset,
may occur following the administration of neuroleptic drugs. The strong
association between neuroleptic medication and extrapyramidal symptoms
suggests that motor dysfunction in patients with schizophrenia might be
entirely due to pharmacological side-effects. However, several lines of
evidence argue against this view. First, both gross and fine motor
disturbances were described in psychotic patients prior to the introduction
of neuroleptic therapy [3-5]. Second, movement disorders similar to
extrapyramidal symptoms have been observed in patients who never
11
Institute of Experimental Psychology, University of Regensburg, 93040
Regensburg, Germany.
2
Department of Psychiatry, University of Regensburg, 93042 Regensburg,
Germany
Address for correspondence: Professor K.W. Lange, Institute of
Experimental Psychology, University of Regensburg, 93040 Regensburg,
Germany, E-mail: oliver.tucha@psychologie.uni-regensburg.de,
klaus.lange@psychologie.uni-regensburg.de Fax:++49 - 941 - 943 4496.
Copyright © 2003 Shunderson Communication, Inc. All Rights of Reproduction Reserved
received any neuroleptic medication [6, 7]. Third discrete alterations
of motor functions have been observed in non-affected first-degree
relatives [8, 9] and in the offspring of patients with schizophrenia[10,
11]. Although the administration of antipsychotic medication can
cause both acute (extrapyramidal) and late onset (tardive dyskinesia)
motor symptoms, it is clear that not all motor alterations in patients
with schizophrenia are induced by drugs.
The introduction of digitising writing tablets has made possible the
examination of specific kinematic aspects of handwriting movements
such as velocity and acceleration of single strokes. Computerized
registration of writing movements has been shown to allow an
objective analysis of psychomotor symptoms in psychiatric patients
[12]. Using the computerized analysis of writing movements, Van
Hoof et al. [12] observed a psychomotor slowing in patients with
schizophrenia on neuroleptic medication. The aim of the present study
was to examine writing performance of patients with untreated
schizophrenia using a digitizing tablet.
2. MATERIAL AND METHOD
The handwriting performance of 12 adult inpatients with untreated
schizophrenia according to the DSM-IV criteria (Table 1) was
assessed. The patients of the present study were free of any
medication. All patients gave informed consent to participate in the
study. Furthermore, 12 healthy adult participants were also assessed.
None of the healthy participants had a history of neurological or
psychiatric disease. The groups were matched according to age, sex,
handedness and education level. Handedness was assessed on the basis
of participants' responses on a short version of the handedness
questionnaire of Rackowski, Kalat and Nebes [13, 14]. None of the
subjects had been compelled by education or illness to learn to write
with the non-preferred hand in early childhood or youth.
Characteristics of groups are summarized in Table 2. The groups did
not differ in sex, age, education or handedness.
The participants were asked to write the sentence "Ein helles
grelles Licht" ("A bright and glaring light"). This task was repeated
twice so that the sentence was written a total of three times by each
subject. Before the start of these writing tasks, several practice trials
were undertaken in order to allow the subjects to become accustomed
to the writing tablet. The tablet was constructed to resemble a common
desk pad in order that subjects could produce their usual handwriting.
No restrictions of posture, speed or size of writing were imposed. The
sentences were written on unruled white paper (size 297 x 210 mm).
A digitising tablet (WACOM IV, Wacom, München, Germany)
with a specific pen containing a normal ink refill was used for the
recording of kinematic data of handwriting movements. The position
of the pen on the tablet, velocity and acceleration were measured
continuously during writing. The digitising tablet used in this study
had a maximum sampling rate of 200 Hz. Data was stored on a
personal computer which was connected to the tablet. Kinematic data
were calculated and smoothed using nonparametric regression methods
(kernel estimators) devised by Marquardt and Mai [15]. It was possible
to localise the tip of the pen with an accuracy of 0.2 mm in both
directions (x / y). Movements of the pen tip above the paper, up
1
The International Journal of Forensic Document Examiners

Table 1. DSM-IV Criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following symptoms, each present for a significant portion of time during a 1-month period (or less
if successfully treated):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., affective flattening, alogia or avolition).
B. Social/occupational dysfunction.
C. Duration: Continuous signs of the disturbance persist for at least six months. This 6-month period must include at least one month of symptoms that
meet Criterion A and may include periods of prodromal or residual symptoms.
D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out.
E. Substance/general medical condition exclusion: The symptoms are not due to the direct physiological effects of a substance or a general medical
condition.
F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the
additional diagnosis of Schizophrenia is made if prominent delusions or hallucinations are also present for at least a month (or less if successfully
treated).

Table 2.Characteristics of patients with untreated schizophrenia and healthy subjects (means ± S.E.)

Variable ealthy Patients with untreated

participants schizophrenia
(n = 12) (n = 12)

Sex (female / male) 4/8 4/8

Handedness a (right / left / ambidextrous) 7/2/3 7/2/3
Age (in years) 30.3 + 2.7 30.4 + 2.6
Education (in years) 11.0 + 0.5 10.4 + 0.6

a
Assessment using a short version of a handedness questionnaire

to a maximum of 1.3 cm, could also be recorded. Data processing was
performed with a computer program for the analysis of handwriting
movements [16].
For data analysis, the total writing time (movement time) and the
distance of the writing trace of the test sentence was recorded per trial.
Movement time (in ms) was defined as the time between the first and final
movement within the writing of the test sentence. Distance (in mm) was
operationalized as the distance covered by the pen during the writing of
the test sentence. For further analysis, a mean movement time and a mean
distance was calculated for each subject. Furthermore, the letter
combination "ll" of the German words "helles" (bright) and "grelles"
(glaring) were taken for the assessment of kinematic aspects of
handwriting. The letter combination "ll" was chosen since these letters
represent a simple letter combination which is usually written with the
letters joined. Furthermore, while writing the letter combination "ll", the
pen is not lifted from the tablet. In the evaluation of kinematic data, the
mean number of inversions of the direction of the velocity (NIV) and
acceleration profiles (NIA) of the letter combination "ll" were calculated.
Data analysis focused on the vertical component of the strokes.
Kinematic analysis of the letter combination "ll" was performed, since
the examination of the dynamic and static writing trace may often require
its segmentation into meaningful units. From a motor viewpoint, single
letters and in particular single strokes represent the smallest relevant units
of the handwriting movement [17]. The motion parameters (e.g. movement
time, number of inversions of velocity and acceleration profiles) were
chosen, since these parameters have been shown to be sensitive measures
for pathology of handwriting movements. Statistical analysis was
performed using the Wilcoxon-test. An alpha level of .05 was applied for
statistical analysis.
RESULTS
Movement Time and Distance
In comparison to healthy participants, patients with untreated
schizophrenia displayed an increased movement time (Z = -.196; p = .050)
although the distance covered during writing did not differ between groups
(Z = -1.10; p = .272). Handwriting data of groups are presented in Table
3.
Number of Inversions in Velocity (NIV) and Acceleration (NIA)
Significant differences between groups were observed in the number
of inversions in velocity (Z = -1.96; p = .050) and acceleration profiles (Z
= -2.35; p = .019). In patients with untreated schizophrenia a reduced
automation of handwriting was found, manifesting itself in an increased
number of inversions of both velocity and acceleration profiles (Figure 1).
DISCUSSION
In the present study, kinematic aspects of handwriting movements of
patients with untreated schizophrenia were examined using a digitizing
tablet. In comparison to healthy participants, patients with untreated
schizophrenia displayed an increased movement time, although the

2 Copyright © 2003 Shunderson Communications, Inc. All Rights of Reproduction Reserved


distance covered during writing did not differ between groups. These
results suggest that the slowing of handwriting movements in patients with
schizophrenia is part of the disease and not just a side-effect of medication.
However, this slowing may be further increased by the administration of
neuroleptic drugs.
In comparison to control subjects, patients with untreated
schizophrenia showed a reduced automation of handwriting, manifesting
itself in an increased number of inversions of both velocity and
acceleration profiles. As Mai and Marquardt [16] reported, automated and
non-automated handwriting movements can be distinguished from one
another by profiles of velocity and acceleration. Single strokes of
automated movements lead to a smooth course and have only one peak
(inversion of the direction) and a bell shaped course in their velocity
profiles. Therefore, a more severe dysfluency of handwriting is reflected
in a higher number of inversions in velocity [18-20]. An analysis of style
of handwriting revealed that patients did not show higher numbers of
errors such as scribbles than healthy participants. The longer movement
time and the increased number of inversions (of velocity and acceleration
profiles) found in patients may, therefore, not be the result of an altered
style of handwriting. However, it should be considered that slower
movements tend to have more secondary submovements than moderate or
fast movements. These submovements may be related to a higher number
of inversions of velocity and acceleration profiles. However, a correction
of the number of inversions for writing time revealed also a less fluent
handwriting of patients with untreated schizophrenia. The present results
suggest that, as well as a slowing of writing movements, the fluency of
handwriting is affected in patients with untreated schizophrenia. The aim
of future studies could be to determine whether and to what extent
neuroleptic medication contributes to the disturbances of handwriting
movements in these patients.
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