4. CLASSIFICATION
DISORDERS OF ADAPTIVE MOVEMENT
DISORDERS OF NONADAPTIVE MOVEMENT
MOTOR SPEECH DISTURBANCES
DISORDERS OF POSTURE
ABNORMAL COMPLEX PATTERN OF BEHAVIOUR
DRUG INDUCED MOVEMENT DISORDER
5. DISORDERS OF NON ADAPTIVE MOVEMENTS
Spontaneous Movements- Motor Habits that are not goal directed
and that tend to become more frequent during anxiety
Eg: scratching of head,stroking,putting the hand in front of mouth
clearing throat etc.
Displacement activity-Normal motor habits occurring when
individuals frustrated or is uncertain about their choice of
behaviour pattern.
6. STEREOTYPY
Repetitive nongoal directed action that is carried out in a uniform
way.
A stereotypy may be a simple movement or a stereotyped or
recurrent utterance
Stereotypies may be simple movements such as body rocking, or
complex such as self caressing, crossing and uncrossing legs and
marching in place.
7. It may be possible to discern the remnants of
a goal directed movement in stereotypy.
They are found in people with schizophrenia, intellectual
disability, autism spectrum disorders, tardive dyskinesia, and
stereotypic movement disorder
8. TICS
Sudden involuntary twitchings of small groups of muscles and are
usually reminiscent of expressive movements or defensive
reflexes.
Face is the most commonly affected part of body.
Eg: Blinking,Distortions of Forehead,nose or mouth etc.
9. They can occur after encephalitis or indicate the onset of Gilles de
la Tourette syndrome or to indicate the onset of torsion distortion,
huntington’s disease, neuroacanthocytosis
Psychogenically determined motor habit or through constitutional
predisposition that is brought to light by emotional tensions.
10. Giles de la Tourette syndrome
Childhood onset neuro developmental disorder that is
characterized by several motor and phonic tics.
Tics usually develop before 10 year of age exhibit waxing and
waning course and typically improve with age.
11. TREMORS
Tremors are rhythmic oscillatory movements involving one or
more body parts.
Most common of all involuntary movements
Can involve hands, arms, eyes, face, head, vocal cords, trunks,
legs.
Seen in anxiety disorder , conversion disorders, drug withdrawal,
parkinsonism, thyrotoxicosis.
12. POSTURAL AND ACTION TREMORS
Postural tremor refer to tremor that is present when the limbs and
trunk are actively maintained in certain positions.
Action tremor are characterised by relatievely rhythmic
outbursts of grouped motor neuron discharges that occur not
quite synchronous and simultaneously in opposing muscle
groups.
Action tremors are of several different types.
13. ALCOHOL WITHDRAWAL TREMORS
Special type of action tremor
Le Febvre – D Amour and colleagues have described two different
alcohol withdrawal tremors:
>8hz, continuous activity in antagonist muscles, responsive to
propranolol
<8hz, discrete outbursts of EMG activity occuring synchronously in
antagonistic muscles
14. ENHANCED PHYSIOLOGIC TREMORS
One type of action tremor
Exaggeration of normal /physiologic tremor
Same frequency as physiologic tremor 10hz
15. STATIC TREMORS
Tremors occurring in hands,hea and upper trunk when patient is
at rest.
Anxiety,Parkinsonism,Alcohol Dependence syndrome and
Thyrotoxicosis.
It can also be Familial.
16. ORGANIC TREMORS
They vary in intensity from day to day and are made worse by
emotional disturbance.
INTENTION TREMORS
It occurs as the goal of voluntary movement is being reached and
is associated with cerebellar disorders and multiple sclerosis.
17. ESSENTIAL TREMORS
Commonest type of tremor
Lower frequency 4-8hz
Unassociated with neurologic changes
Familial/ hereditary tremor- only neurologic abnormality
Most common in late second decade
Worsened by emotion, exercise and fatigue
Begins in arms, symmetrical
Advanced cases in jaw, lips, tongue, pharynx , larynx
18. PARKINSONIAN TREMORS
Coarse rhythmic tremor with a frequency of 3 to 5 hz
Characterised by burst of activity present between opposing muscle
groups.
Localised in one or both hands and forearms and less frequently in the
feet, jaw, lips or tongue.
It occurs when limb is in an attitude of repose and is suppresses or
diminished by willed movement - resting tremors.
If the tremulous hand is completely relaxed, as it when the arm is fully
supported at the wrist and elbow, tremor usually disappears
19. Parkinsonian tremor takes the form of flexion- extension and
abduction- adduction of the fingers- pill rolling tremors.
Cog wheel effect- which is percieved by the examiner on passive
movement of the extremities (NEGRO’S SIGN)- is probably no
more than a palpable tremor superimposed on rigidity
20. HYSTERICAL TREMORS
Restricted to one single limb, gross in nature
Diminish in amplitude or disappear when the patient is distracted
“Chasing the tremor”
Exaggeration of the tremors by loading the limb
21. SPASMODIC TORTICOLLIS
Spasm of the neck muscles ,especially the sternomastoid,which
pulls the head towards the same side and twists the face in
opposite direction.
Initially it lasts for few minutes,later it becomes permanent
22. CHOREA
It is quick,irregular and predominantly distal involuntary
movement.
Seen in rest and in action.
They resemble fragments of expressive or reactive movements.
23. In Huntingtons chorea patient may attempt to disguise the choreic
movements by turning them into voluntary or habitual ones.
Eg: sudden jerking of arm may be continued into a smoothing
down of hair at the back of head.
24. ATHETOSIS
Slow writhing movements involving fingers , hands toes, feets
which can bring about strange postures in the body.
Can be seen in catatonia, cerebral palsy and vogt’s syndrome
CHOREOATHETOSIS
Movement of intermediate speed,between the quick,fleeting
movements of chorea and the slower,writhing movements of
athetosis.
25. PARAKINESIA
Seen in catatonia
Described by Kleist (1943)
Constant motion with grimaces and exaggerated smiles, twitch or
jerk continuously
Parakinetic catatonia
28. AUTOMATIC OBEDIENCE
Patient carries out every instruction regardless of consequences.
Seen in Catatonia and also in Dementia.
29. PERSEVERATION
Senseless repetition of a goal directed action that has already
served its purpose.
More obvious when speech is affected.
Two forms of perseveration:Logoclonia and Palilalia
30. LOGOCLONIA
Last syllable of the last word is repeated.
Eg: I am well today-ay-ay-ay-ay
PALILALIA
Repeats the perseverated word with increasing frequency.
31. Freeman and Gathercole described three types of perseveration
Compulsive repetition:Act is repeated until the patient receives
another instruction.
Impairement of switching:Repetition continues after the patient
has been given a new task.
Ideational perseveration:Patient repeats words and phrases during
their reply to a question.
32. Compulsive repetition is more common in inviduals with
schizophrenia
Impairement of switching is more common in individuals with
dementia.
Ideational perseveration is equally common in both groups
33. ECHOPRAXIA
Patients imitate simple actions that they see such as
handclapping, snapping fingers etc.
ECHOLALIA
Patients echoes a part or whole of what has been told to them.
Words are echoed irrespective of whether the patient
understands it or not.
34. FORCED GRASPING
Despite frequent instruction not to touch the examiners hands the
patient continues to do so.
Seen in Catatonia and Dementia
35. Grasp reflex
Patient automatically grasps all objects placed in his hand,
Magnet reaction- Examiner rapidly touches the palm of patients
hand and then withdraw, the patients hand may follow the
examiners fingers.
Seen in Catatonia and Organic brain disorders.
36. MITMACHEN (COOPERATION)
Body can be put into any position without any resistance on the
part of the patient, although they have been asked to resist all
movement
Once let go of the body part that has been moved, it returns to
the resting position
Seen in catatonia and neurological disorders affecting brain.
37. MITGEHEN
Extreme form of cooperation .
Patient moves their body in direction of slightest pressure on part
of the examiner.
38. GEGENHALTEN (OPPOSITION)
Patient will oppose all the passive movements with same degree
of force as being applied by the examiner.
39. NEGATIVISM
Accentuation of opposition.
Motiveless resisitance to all interference and may or may not be
associated with an outspoken defensive attitude.
Passive and Active Negativism
Catatonia,Severe learning disability and Dementia.
40. AMBITENDENCY
Mild variety of negativism
Patient makes a series of tentative movements that do not reach
the intended goal when they are expected to carry out a voluntary
action.
41. Based on Motor symptoms patients with chronic schizophrenia
and catatonic features are classified into syndromal groups.
Class 1 – Automatic phenomena such as automatic obedience,
mitgehen and waxy flexibility.
Class 2 – Repetative or echo phenomenon such as
stereotypy,perseveration,verbigeration,mannerisms and
grimacing.
Class 3 – withdrawal phenomena such as
immobility,mutism,staring,posturing and withdrawal
Class 4- Agitated/Resistive phenomenon such as
impulsivity,excitement,negativism and combativeness
Spontaneous movements are also called involuntary motion as they are an automatic motion very often the person may not be even aware that he is doing it.
Tics are usually preceded by an urge to move that can be suppressed voluntarily but only for short time as the urge to perfom the action builds up in patient.
Huntington disease-Autosomal dominant disorder
progressive atrophy of the basal ganglia
Onset 3 to 50 yrs, death usually after 12 yrs of onset
Neuroacanthocytosis-group of genetically defined disease characterized by association of red blood cell acanthocytosis and progressive degeneration of basal ganglia. Examples are autosomal recessive chorea acanthocytosis and x linked Mc leod syndrome
Tremors can be physiologic or pathologic.
Best elicited by holding the arms outstretched with fingers spread apart, is characteristic of intense fright and anxiety, certain metaboilc disturbances hyerthyroidism, hypercortisolism, hypglycemia, phaeochromocytoma intense physical exertion, withdrawal from alcohol, and other sedative drugs- lithium, nicotinic acid , xanthines, coticosteroids
If the affected hand and arm are restrained by the examiner the tremor may move to proximal part of the limb or to another another of the body
Brief semi directed irregular movements that are not repetitive or rhythmic, but appear to flow from one muscle to the next, associated with athetosis
For eg: sudden jerking of hands of the arm may be continued into a smoothing down of the hair at the back of the head.
In huntingtons chorea the face, uPPer trunk and arms are most affected by the coarse Jerky movements ( caudate nucleus putamen and cerebral cortex involvement). In sydenhams chorea the movemnt are less jerky and somewhat slower than huntingtons chorea. The arms and face are affected and respiration is often irregular because it is made difficult by movts of the spine and abdominal wall.
Kraepelin would ask the patient to put out their tongue and he would prick it with a pin.patients with automatic obedience continued to put their tongue out when asked to,although every time they did so their tongue was pricked.
Very often patient is unable to go beyond a phrase pr word which they go on repeating and may repeating in reply to another question.
Both palilalia and logoclonia can occur in organic brain disorders and schizophrenia.
The examineroffers his hand to patient and the patient will shake it.then examiner will explain to patient that on all future occasions when examiner offers his hand the patient should not touch it.after this examiner talks for a few minutes then again offers his hand if forced grasping is present the patient will shake th examiners hand.
Eg; if doctor applies light pressure on occiput of patient who is standing leads to bending of neck,flexing of trunk and if pressure continues patient may fall forward.
Not obvious when passive movements are carried out very gently and it may appear when the examiner attempts to produce forceful passive movements.
Passsive- when all interference is resisited and orders are not carried out
Active- command negativism –the patient does exact opposite of what they are asked to do.
Eg; whenexaminer puts his hand out to shake hands the patient moves their right hand towards examiners hand,stops, start moving hand stops and so on, until the hands fibally comes to rest without touching the examiners hands.
