SUBJECTIVE MOTOR DISORDER• Obsessions and Compulsions: patient experience them against their will butsense of personal possession of act is not lostalthough control over voluntary activity is lost.• Delusion of passivity: here control over thought, action and feeling islost as well as they are experienced as beingmanufactured against his will by some foreigninfluences.
OBJECTIVE MOTOR DISORDERS• Disorders of adaptive movements a) Disorders of expressive movement b) Disorders of reactive movements c) Disorders of goal-directed movements• Disorders of non-adaptive movements a) Spontaneous movements b) Abnormal induced movements
• Motor speech disturbances• Disorders of posture• Abnormal complex patterns of behavior a) Non-goal-directed abnormal patterns ofbehavior b) Goal-directed abnormal patterns ofbehavior• Movement disorders associated with antipsychotic medication
DISORDERS OF ADAPTIVE MOVEMENTS• A. Disorders of expressive movementExpressive movement involves face, arm, hands andthe upper trunk. Extent vary with emotional statesand range may vary in different cultures.1. OMEGA SIGNThe occurrence of a fold like the Greek letter omegain the forehead above the root of the noseproduced by the excessive action of the corrugatormuscle. It was described by Athanassio; seen indepression.
2. Verugath foldThe main fold in upper lid is angulated upwardsand backwards at the junction of the inner thirdwith the middle third of the folds; seen indepression.3. Other expressive movement disorder indepressiona. Lack of facial expression and it’s mobility.b. Diminished or absent gestures in retarded depression. Patient walk slowly and bowed down as it carrying heavy loads on shoulder.
c. restlessness and apprehension in agitatedand anxious depression. Patient sit moving handand feet , fidgeting. Some patient may stand upand sit down again.4. Expressive movement disorder in catatoniaa. stiff expressionless facies and scantyexpressive movement of body.b. excessive grimacing and facial contortion.c. rounded lips thrust forward in tubularmanner called as Schnauzkrampf ( snout spasm).
5. Expressive movement disorder in mania:a. Undue cheerfulness and wide expansivegestures.b. Emotional lability.c. Ecstasy – rapt intense look. Patient isincommunicative and completely absorbed byintense experiences.B. DISORDERS OF REACTIVE MOVEMENT:Reactive movements are immediate automaticadjustments to new stimuli, as needed inresponse to a threat or while attending tosource of a percept.
a. startle reflex – in severe anxiety reactivemovements are prompt and excessive. b. loss of reactive movements in catatonia dueto obstruction, which are carried out in stiffdisjointed manner.C. DISORDERS OF GOAL DIRECTED MOVEMENTS:Usually all these movements are carried outwithout any deliberate awareness on the part ofthe patient. These movements reflectpersonality as well as the current mood state ofthe subject.
a. Psychomotor Retardation :It is experienced subjectively as difficulty to initiateand carry out any activity. There is lack ofexpression with furrowed eyebrows and downgazedeye. b. Blocking or Obstruction ( sperrung ):It can be defined as irregular stroboscopicmovement in perception, in which the patientwould not be able to initiate the movementdepending upon the will but with the chance factor.Kleist described that the cardinal feature of theobstruction is the “reaction at the last moment”. Asthe severity increases it gradually ascends toakinesia and then even to stupor.
c. Mannerism :cardinal feature of mannerism are:Unusual repetitionExaggeration of normal and adaptive actPersonal significanceGoal- directedMannerism can be found in normal subjects,abnormal personalities, schizophrenia andneurological disorders.
In non-psychotic mannerism is likely to occur when subject has need to be noticed but not has capacity be intellectually outstanding.In abnormal personalities it may be result of lack of control over motor behavior often associated with lack of self-confidence.Schizophrenic mannerism may arise from delusional ideas.In neurological disorders mannerism are result of lack of pyramidal and extrapyramidal systems.
NON ADAPTIVE MOVEMENTS• A. SPONTANEOUS:Spontaneous movements are automatic motion,balanced by the sympathetic and parasympatheticnervous systems, and are called involuntary motion.1. TicsThey are sudden involuntary twitching of small groups ofmuscles that are reminiscent of expressive movementsand defensive reflexes. The characteristic feature of tic isthat the movement is usually preceded by an urge tomove, and it can be suppressed for a short time (about30-60 sec) by voluntary effort. They are rapid, recurrent,non-rhythmic, stereotyped.
• Simple motor tics- are eye blinking, nose wrinkling, neck jerking, shoulder shrugging, facial grimacing, and abdominal tensing. These tics usually last less than several hundred milliseconds.• Complex motor tics- include hand gestures, jumping, touching, pressing, facial contortion, twirling when walking, and assuming and holding unusual postures. These tics are longer in duration, lasting seconds or longer
2. TremorTremor is an involuntary, somewhat rhythmic,muscle contraction and relaxation involving to-and-fro movements (oscillations or twitching) of one ormore body parts.Tremors are classified as normal (or physiologic)and abnormal (or pathologic). It can be rest tremor(Parkinson’s disease tremor, alcoholism,thyrotoxicosis) or action tremor. Action tremorsagain can be of two types: postural tremor(Physiologic tremor, Essential tremor, Drug-inducedtremors) and kinetic tremor (Intention tremor andTask-specific tremor) .
3. Choreais a quick, irregular, and predominantly distal involuntarymovement. The term ‘semi purposive’ has been used tofacilitate its identification. These jerky movementsresemble fragments of expressive or reactive movements.4. AthetosisAthetosis is a condition in which the spontaneousmovements are slow, twisting and writhing, which bringabout strange postures of the body, especially of the hands.The maintained posture is interrupted by relatively slow,sinuous, purposeless movements that have a tendency toflow into one another. Choreoathetosis is a movement ofintermediate speed, between the quick, fleetingmovements of chorea and the slower, writhing movementsof athetosis.
5. ParakinesiaParakinesia is a term used by Kleist (1943) to describe theoccurrence in catatonic schizophrenic patients of motor activitywhich is reminiscent of, but somehow different from chorea,athetosis, and tics. It consists of a continuous irregularmovement of the musculature so that patients with thissymptom grimace, twitch, and jerk continuously. Patients areusually referred to as parakinetic catatonic, and the olderpsychiatrist used to call the behavior as‘clown like.6. StereotypyStereotypy is a repetitive, seemingly driven, and nonfunctionalmotor behavior. They are repeated movements that are regular(unlike tics) and without any obvious significance (unlikemannerism). It is required to be distinguished from agitation.Unlike mannerism, stereotypy is an abnormal, non- adaptive,non-goal directed and senseless act.
• B. ABNORMAL INDUCED MOVEMENTS Automatic Obedience (also called command automatism) is an exaggerated cooperation with examiner’s request, or repeated movements that are requested once (Bush et al, 1996). The patient carries out every action regardless of the consequences (Hamilton, 1985). How to examine: Reach into pocket and state, ‘stick out your tongue, I want to stick pin into it’. (Bush et al, 1996) Echopraxia is the repetition by imitation of movements of another. The action is not a willed or voluntary one and has a semiautomatic and uncontrollable quality (APA, 2000). Raising an arm over the head is imitated, the patient raising his right arm as the examiner raises his left. Patients do not know why they make these movements and they usually give a silly or inadequate reason for it, denying their illness. Study by Chapman and McGhie on schizophrenic patients revealed that echopraxia usually happens when the patient is trying to communicate with another person, and is more common when he finds it difficult to communicate verbally. Three types of echopraxia has been mentioned corresponding to the different stages of imitation in childhood described by Piaget: Completely automatic echopraxia, Echopraxia to memory images and Voluntary echopraxia.
Perseveration is a senseless repetition of a goal-directed action, which has already served its purpose (Hamilton, 1985). It can be understood under phenomenon categorized as; 1. Pathological repetition of the same response to different stimuli,as in a repetition of the same verbal response to different questions. 2. Persistent repetition of specific words or concepts in the processof speaking. Seen in cognitive disorders, schizophrenia, and other mentalillness. Freeman & Gathercole (1966) studied perseveration inschizophrenia, arteriosclerotic dementia and senile dementia. Theydescribed three types of perseveration: Compulsive repetition, in which the act is repeated until thepatient receives another instruction. Seen more commonly inschizophrenia. Impairment of switching, in which the repetition continues afterthe patient has been given a new task. Seen more commonly in dementia. Ideational perseveration, in which the patient repeats words andphrases during their reply to a question.
• Manifestation of perseveration when speech is affected, due to coarse brain disease, can be of two types (Hamilton, 1985) Logoclonia- The last syllable of the last word isrepeated. Palilalia- Patient repeats the perseverated wordwith increasing frequency.• Perseveration can be distinguished from stereotypy by the fact that the stereotypy is an abnormal, non- adaptive act whereas perseveration is a repetition even when the purpose is served. Stereotypy is non-goal directed whereas perseveration is goal directed. Stereotypy is spontaneous but perseveration is an induced movement.
Mitmachen (cooperation) is also a form of an extreme compliance on the part of the patient. In this despite the instruction to the patient for non-compliance, the patient’s body can be put in any position without any resistance. It is usually found in catatonia and other neurological diseases. It occurs when the patient acquiesces in every passive movement of the body made by the examiner. Mitgehen (going along with) is another kind of excessive compliance in which the examiner is able to move the patient’s body with the slightest touch, but the body part immediately returns to the previous position, unlike waxy flexibility. It is also known as the “anglepoise effect” or “angle poise lamp sign” (Hamilton, 1985). It can be called as an extreme form of mitmachen.
Forced grasping is a phenomenon in which the patient forcibly and repeatedly grasps the hands of an examiner when offered. It is an involuntary flexion of the fingers to tactile or tendon stimulation on the palm of the hand, producing an uncontrollable grasp; which is usually associated with frontal lobe lesions. Commonly seen in chronic catatonia and dementia. Magnet reaction is a reflex in which light finger pressure on a toe pad causes a slow reflex contraction in the lower extremity, which seems to follow the examiners hand, as if drawn by a magnet. Ambitendency is a phenomenon in which the patient alternates between resistance to and cooperation with the examiner’s instructions; for example, when asked to shake hands, the patient repeatedly extends and withdraws the hand. Patient appears “stuck” in indecisive, hesitant motor movements (Bush et al, 1996). It can be regarded as a mild variety of negativism or as the result of obstruction.
Negativism: Patient resists examiner’s manipulations, whether light or vigorous, with strength equal to that applied, as if bound to the stimulus of the examiner’s action. Negativism occurs when the subject consistently does the opposite of what is asked, e.g. asked to open the hands, it is closed tighter (WHO, 1998). Negativism may or may not be associated with a defensive attitude. It can be of two types namely: Passive negativism: When the patient does notfollow the given command and resist any kind of interference. Active or command negativism: When the patientnot only resists the command given, but also does theopposite of what is said. Gegenhalten or opposition all passive movements are opposed with samedegree of force as being applied by the examiner.
MOTOR SPEECH DISORDER Mannerism only a few words may be mispronounced or there may bedistortion of most of the words. Verbal stereotypy words or phrases are repeated continuously. They may bespontaneous or set off by a question. Verbigeration one or several sentences or strings of fragemented words arerepeated continuously. Wurgstimme few schizophrenic speak in strange strangled voice Verbal perseveration
Echolalia is a pathological, parrot like, and apparently senseless repetition of a word or a phrase just spoken (APA, 2000). Jasper (1962) describes it as repetition of everything patient hears in a parrot- fashion. It can also be present in developmental disorders as autism. There are two types of echolalia, namely immediate and delayed echolalia. Immediate echolalia appears to tap into the persons short- term memory for auditory input. This is defined as the repetition of a word or phrase just spoken by another person. Delayed echolalia appears to tap into long-term auditory memory, and for this reason, may be a different phenomenon from immediate echolalia. Because it can involve the recitation of entire scripts, delayed echolalia is often thought to denote evidence of near-genius intellect. There are two described categories of delayed echolalia: No communicative repetition and communicative repetition. The patient echoes a part or the whole of what has been said to him, irrespective of whether he understands them or not. It could be the result of disinhibition of a childhood speech pattern. Echologia (Kleist, 1943): The patient replies to questions by echoing the content of the questions in different words.
DISORDER OF POSTURE Manneristic posture: A manneristic posture is an odd stilted posture that is an exaggeration of a normal posture and not rigidly preserved. Stereotyped posture: It is an abnormal and non-adaptive posture that is rigidly maintained. Psychological pillow is a dramatic posture, in which the supine patient lies with head and shoulders raised as if resting on a pillow. Perseveration of posture: The patient persists with a particular movement that has lost its initial significance. The patient allows the examiner to put his body into strange uncomfortable positions and then maintains such postures for at least one minute and usually much longer (Hamilton, 1985).
Posturing: Patient is able to maintain the same posture for long periods. The classic example of posturing is “crucifix”. Other examples are sitting with upper and lower portions of the body twisted at the right angle, holding finger and hands in odd position. So it can be called as a spontaneous maintenance of postures for extended period of time. Waxy flexibility (flexibilitas cerea): The examiner is able to position the patient in what would be highly uncomfortable postures, which are maintained for a considerable period of time. During reposturing of patient, patient offers initial resistance before allowing himself to be repositioned, best felt during reposturing of patient. Catalepsy: Maintains posture, including mundane (e.g., sitting or standing for long periods without reacting) (WHO, 1998). It is a condition in which a person maintains the body position in which he is placed, observed in severe cases of catatonic schizophrenia. Catalepsy usually lasts for more than one minute and ends with the body slowly sinking back into the resting position. It is often very variable and may even disappear for a day or so only to return again. Unlike waxy flexibility, in catalepsy when the examiner releases the body those muscles which fixes the body in the abnormal position can be felt to contract.
ABNORMAL COMPLEX PATTERNS OF BEHAVIOR A. Non-goal-directed abnormal patterns of behavior Stupor: Unresponsiveness, hypo activity, and reduced or altered arousal during which the patient fails to respond to queries, when severe, the patient is mute, immobile, and does not withdraw from painful stimuli. Stupor can be seen under the conditions of depression, catatonia, epilepsy, cycloid psychosis and coarse brain disease. It is further classified as; Psychogenic stupor: It may occur in the setting of severe psychologicalshock. The patient appears as if ‘paralyzed with fear’ and is unable to retreatfrom danger – can be terminated by sedation and reassurance. Hysterical stupor: It emerges as an acute psychogenic reaction tosevere trauma and then becomes a goal-directed reaction. It is presented bythe subject for some gains, although he is not fully aware of his hiddenmotivation. It tends to occur in appreciation needing personality. Catatonic stupor: In this muscle tension is permanently increased or itvaries from time to time and is associated with obstruction. Significantfeatures are “dead-pan” facial expression, changes in muscle tone, catalepsy,stereotypies and incontinence of urine.
Excitement: It can characterize as an extreme hyperactivity, constant motor unrest which is apparently non-purposeful. This is not to be attributed to akathisia or goal-directed agitation (Bush et al, 1996). Psychogenic excitements may be acute reactions or goal-directed reactions. Acute reactions: Predisposed subjects may react to moderatelystressful situations with senseless violence. Chaotic restlessness rather like a‘storm of movement’ may occur in susceptible subjects during catastrophes,and in unsophisticated and mentally subnormal persons subject to mildstress. Goal-directed reactions: Excitement is part of attention-seekingbehavior. Even during severe excitement, it is usually possible to make contactwith these patients and interrupt the over activity. They seem eager to bepunished and enjoy a good fight. Excitement in depression: Moderately severe agitated depression:takes a mechanical form; patient wanders about restlessly and bewail his fatemonotonously though in severe agitation the patient wrings his handscontinuously, sits up in bed, rocks to and fro and laments; sometimes pickingthe hair, rubbing the face or pulling the hair; the total picture is one of abjectmisery. Catatonic excitement: In such patients body movements are oftenstiff, stilted and violence is usually senseless and purposeless(Hamilton,1985).
B. Goal-directed abnormal patterns of behavior: Compulsive rituals: These are characteristic of obsessive compulsive disorder, and are the motor act results from obsessions. Often manifested in the forms of cleaning, checking and repeating. Brutal and aggressive behavior: It is often socially determined. Many a times in conditions like schizophrenia, it is manifested because of the involvement of hallucinations, persecution or referential ideas, or assuming others as a part of delusional system. In mood disorders too, it is very much likely to be manifested either due to elevation of mood itself or due to accompanied psychosis. Extended suicide’: It is a condition in which the patient with delusional depression murders his children in the mistaken belief that they have incurable inherited insanity or some foul disease. The children are therefore murdered in the mistaken belief that they would be ‘better off dead’. Disinhibition resulting from organic brain disease, mania or schizophrenia may give rise to promiscuous behavior, leading to increased risk of pregnancy and sexually transmitted disease. Dissociative fugue: It is characterized as a fugue state, formally Dissociative Fugue, previously called Psychogenic Fugue. It is a rare psychiatric disorder characterized by reversible amnesia for personal identity, including the memories, personality and other identifying characteristics of individuality. Dissociative fugue usually involves unplanned travel or wandering, and is sometimes accompanied by the establishment of a new identity.
MOVEMENT DISORDERS ASSOCIATED WITH ANTIPSYCHOTIC MEDICATION Drug induced dyskinesia: It can be applied to any type of involuntary movement but is most frequently employed for the rather complex choreic and dystonic movements that occur after the prolonged treatment with neuroleptics. The term neuroleptic means “that which takes neurons” was coined by Deniker. It occurs in the form of stereotypy, defined as repetitive, coordinated, seemingly purposeful movements, other drug –induced dyskinesias are manifested by dystonia, chorea, tics, tremors and miscellaneous involuntary movements. Acute dystonia: Acute dystonic reaction is sustained, repetitive, patterned, muscle spasm resulting in twisting, squeezing, pulling, and often painful posturing. The symptoms may occurs within hours after administration of the offending drug and may be the first extra-pyramidal side effect encountered with the neuroleptic. Acute and tardive akathisia: The term akathisia (not sitting) was first introduced by Haskovec in 1901 to describe individuals unable to remain in a seated position. Akathisia may occur within the first three months of neuroleptic therapy and may persist as tardive akathisia even when the offending drug is stopped. It is characterized by a subjective feeling of restlessness accompanied by motor stereotypies. The restlessness has been described using such phrases as “nervousness”.
Tardive dyskinesia: It is a distortion of voluntary movements with involuntary muscular activity. The American Psychiatric Association Task Force defines tardive dyskinesias as abnormal involuntary movement resulting from treatment with a neuroleptic drug for three months in a patient with no other identifiable cause for movement disorder (Joesph & Young, 1999). The essential features of Neuroleptic-Induced tardive dyskinesia are abnormal, involuntary movement of the tongue, jaw, trunk, or extremities that develop in association with the use of neuroleptic medication. The movements are present over a period of at least 4 weeks and may be choreiform( rapid, jerky, non repetitive), athetoid (slow, sinuous, continual), or rhythmic (e.g., stereotypies) in nature. The signs or symptoms develop during exposure to a neuroleptic medication or within four weeks of withdrawal from an oral (or within 8 weeks of withdrawal from a depot) neuroleptic medication (APA, 2000).Tardive dyskinesia is often a persistent disorder, but spontaneous remissions are frequently encountered, particularly in the younger population. Tardive tremor: It is a relatively rare form of tardive dyskinesia. This rhythmic movement is distinguishable from the more common stereotypy in that it consists of an oscillatory movement rather than coordinator, seemingly purposeful movement seen in tardive stereotypy. Tardive tremor differs from tremor observed in patients in parkinsons disease in that it is predominantly postural and kinetic and it is not necessarily accompanied by other parkinsonian signs.
Tardive Dystonia: It is a persistent dystonic movement disorder and therefore it differs from acute transient dystonic reaction. Criteria for its diagnosis include the presence of chronic dystonia, prior or concurrent neuroleptic use, exclusion of non causes of secondary dystonia, and a negative family history for dystonia. It is characterized by sustained, slow or rapid twisting movements involving the face, neck, trunk, or limbs, tardive dystonia may occur after only three days of antipsychotic treatment, but usually it follows months of neuroleptic therapy. Tardive tourettism: Gilles de la Tourette syndrome is a neurobehavioral disorder characterized by motor and phonic tics and a variety of behavioral problems. Motor tics are coordinated involuntary movements occurring in patterned sequences in a spontaneous, unpredictable, abrupt, and transient manner. Involuntary vocalizations, repetition of words as phrases (echolalia), use of obscenities (coprolalia), and mimicking of gestures (echopraxia) often occurs in the patient with Tourette syndrome. Tardive Myoclonus: Myoclonus, a jerk- like contraction of muscle group may be rhythmic or arrhythmic, arising from cortical, subcortical, and spinal cord structures. Myoclonus must be differentiated from other movement disorders. Tics differ from myoclonus in that tics can be voluntarily controlled and are more complex movements. Dystonic contractions are more prolonged and often twisting whereas myoclonic jerks are brief and simple. Tremors are oscillatory movements that differentiate them from rhythmic myoclonus which are secondary to repetitive agonist muscle contractions. Myoclonus differs from chorea in that chorea is a random flow of brief contractions.
• Neuroleptic Malignant Syndrome: (NMS) was first described by Delay and Deniker in 1968, and is believed to be a consequence of impaired hypothalamic and striatal dopamine transmission or sudden withdrawal from dopamine therapy. NMS is characterized by hyperpyrexia, muscular rigidity, autonomic dysfunction, and alternations in consciousness.• Serotonin Syndrome: Concurrent administration of SSRI with a MAO inhibitor, L-tryptophan, or lithium can raise plasma serotonin concentrations to toxic levels, producing a constellation of symptoms called the serotonin syndrome. Serotonin syndrome is composed of Diarrhea, Diaphoresis, Tremor, Ataxia, Myoclonus, Hyperactive reflexes, Disorientation, and lability of mood (Sadock and Sadock, 2007).• Rabbit Syndrome: The rabbit syndrome is another neuroleptic drug induced disorder. It is probably best conceptualized as an acute EPS phenomenon. It was first described in 1972 as “perioral muscular movements strikingly imitating the rapid, chewing-like movements of a rabbit’s mouth.” These movements did not involve the tongue and were limited exclusively to the territory of the oral and masticatory muscle. This clinical picture was immediately labeled “the Rabbit syndrome”. The primary signs of rabbit syndrome involve rapid perioral movements. These are principally in the vertical plane and do not involve horizontal, or rotator jaw motions.