Egion and on its role in the pathophysiology of PG. A limitation of the cross-sectional design employed here is its inability to resolve the origin of elevated NSSs in PG. One possibility is that they are preexisting vulnerability markers [83]. A growing body of work points to compromised cortical function reflected in NSSs that precedes the emergence of mood, anxiety [57], psychotic [84?6] and obsessive-compulsive [57,87] symptoms. Neurological soft signs are also commonly observed in mentally healthy relatives of schizophrenic patients [88?1], further suggesting their preexisting and inheritable trait-like nature. Notably, as suggested by twin studies, PG has a robust genetic component ranging from 50 to 60 [92]. Greater premorbid hyperactivity, impulsivity, and antisociality have been found in PG subjects [93]. A second possible origin of NSSs in PG is that they are acquired, e.g., they are a consequence of excessive gambling. People who gamble lose money, and a consequence of losing money may be increased stress, possibly leading to brain alterations. Pathological gambling is indeed associated with an exaggerated sympathoadrenal tone suggestive of heightened levels of stress and arousal [94] at baseline [95,96] and while engaged in gambling [8,9,97?00]. Subjects with PG have greater amygdala activation in response to the alpha-2 adrenergic antagonist, yohimbine [60]. Research in laboratory animals [101] and humans [102,103] has shown that increased sympathetic activity may cause vasospasm and microthrombosis resulting in diminished cerebral perfusion. It would be of interest to test whether antiadrenergic agents (e.g., clonidine or prazosin) might moderate the NSSs observed here. However, the BIBS39 reversibility of NSSs is questionable [39], given that this has only been found in 11967625 some [104] but not in all OCD patients [105?07], and not in patients with bipolar disorder [108] or schizophrenia [107,109]. In sum, resolution of the risk factor vs. acquired origin interpretation of the observed NSSs in PG, as well as NSSs’ possible response to treatment and/or their ability to predict [37,110] such a response (as has been shown for OCD patients) will require prospective clinical trials. The present design is unable to inform the question as to whether the same visual agnosia displayed by the PG subjects on the DROT is not likewise implicated in their constructional apraxia on the figure 
copying task. Disentangling this would require an exclusively motor processing task that does not involve visual input [27]. Such tasks are included in the full assessment battery of previously reported NSSs [27], which assesses motor coordination and both motor and sensory integration. In conclusion, the data presented here shed light on the neurological function of patients with PG and suggest that NSS examination has heuristic value for illuminating brain abnormalities in 
this disorder. Pathological gambling offers a unique model as it represents an addictive behavior in the absence of theNeurological Soft Signs and GamblingTable 2. Group medians and mean (6SDs) for the performance indices on the Copy Figure, Detection and Recognition of an Object and the Road Map tests.TaskPG (n = 21) Median Mean ?SDControl (n = 10) Median Mean ?SDWilcoxon Exact TestpCFT (score; 0?) 1. Diamond 2. Cross 3. Necker cube 4. Smoking pipe 5. Hidden elimination cube 6. get 3397-23-7 pyramid 7. Dissected pyramid Average DROT error (#) High noise Low noise RMT error (#) doi:10.1371/journal.pone.Egion and on its role in the pathophysiology of PG. A limitation of the cross-sectional design employed here is its inability to resolve the origin of elevated NSSs in PG. One possibility is that they are preexisting vulnerability markers [83]. A growing body of work points to compromised cortical function reflected in NSSs that precedes the emergence of mood, anxiety [57], psychotic [84?6] and obsessive-compulsive [57,87] symptoms. Neurological soft signs are also commonly observed in mentally healthy relatives of schizophrenic patients [88?1], further suggesting their preexisting and inheritable trait-like nature. Notably, as suggested by twin studies, PG has a robust genetic component ranging from 50 to 60 [92]. Greater premorbid hyperactivity, impulsivity, and antisociality have been found in PG subjects [93]. A second possible origin of NSSs in PG is that they are acquired, e.g., they are a consequence of excessive gambling. People who gamble lose money, and a consequence of losing money may be increased stress, possibly leading to brain alterations. Pathological gambling is indeed associated with an exaggerated sympathoadrenal tone suggestive of heightened levels of stress and arousal [94] at baseline [95,96] and while engaged in gambling [8,9,97?00]. Subjects with PG have greater amygdala activation in response to the alpha-2 adrenergic antagonist, yohimbine [60]. Research in laboratory animals [101] and humans [102,103] has shown that increased sympathetic activity may cause vasospasm and microthrombosis resulting in diminished cerebral perfusion. It would be of interest to test whether antiadrenergic agents (e.g., clonidine or prazosin) might moderate the NSSs observed here. However, the reversibility of NSSs is questionable [39], given that this has only been found in 11967625 some [104] but not in all OCD patients [105?07], and not in patients with bipolar disorder [108] or schizophrenia [107,109]. In sum, resolution of the risk factor vs. acquired origin interpretation of the observed NSSs in PG, as well as NSSs’ possible response to treatment and/or their ability to predict [37,110] such a response (as has been shown for OCD patients) will require prospective clinical trials. The present design is unable to inform the question as to whether the same visual agnosia displayed by the PG subjects on the DROT is not likewise implicated in their constructional apraxia on the figure copying task. Disentangling this would require an exclusively motor processing task that does not involve visual input [27]. Such tasks are included in the full assessment battery of previously reported NSSs [27], which assesses motor coordination and both motor and sensory integration. In conclusion, the data presented here shed light on the neurological function of patients with PG and suggest that NSS examination has heuristic value for illuminating brain abnormalities in this disorder. Pathological gambling offers a unique model as it represents an addictive behavior in the absence of theNeurological Soft Signs and GamblingTable 2. Group medians and mean (6SDs) for the performance indices on the Copy Figure, Detection and Recognition of an Object and the Road Map tests.TaskPG (n = 21) Median Mean ?SDControl (n = 10) Median Mean ?SDWilcoxon Exact TestpCFT (score; 0?) 1. Diamond 2. Cross 3. Necker cube 4. Smoking pipe 5. Hidden elimination cube 6. Pyramid 7. Dissected pyramid Average DROT error (#) High noise Low noise RMT error (#) doi:10.1371/journal.pone.
