1. MOTOR DISORDERS IN
PSYCHIATRY
DR. RAJEEV

2. SUBJECTIVE MOTOR DISORDER
• Obsessions and Compulsions:
patient experience them against their will but
sense of personal possession of act is not lost
although control over voluntary activity is lost.
• Delusion of passivity:
here control over thought, action and feeling is
lost as well as they are experienced as being
manufactured against his will by some foreign
influences.

3. 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

4. • Motor speech disturbances
• Disorders of posture
• Abnormal complex patterns of behavior
a) Non-goal-directed abnormal patterns of
behavior
b) Goal-directed abnormal patterns of
behavior
• Movement disorders associated with
antipsychotic medication

5. DISORDERS OF ADAPTIVE MOVEMENTS
• A. Disorders of expressive movement
Expressive movement involves face, arm, hands and
the upper trunk. Extent vary with emotional states
and range may vary in different cultures.
1. OMEGA SIGN
The occurrence of a fold like the Greek letter omega
in the forehead above the root of the nose
produced by the excessive action of the corrugator
muscle. It was described by Athanassio; seen in
depression.

6. 2. Verugath fold
The main fold in upper lid is angulated upwards
and backwards at the junction of the inner third
with the middle third of the folds; seen in
depression.
3. Other expressive movement disorder in
depression
a. 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.

7. c. restlessness and apprehension in agitated
and anxious depression. Patient sit moving hand
and feet , fidgeting. Some patient may stand up
and sit down again.
4. Expressive movement disorder in catatonia
a. stiff expressionless facies and scanty
expressive movement of body.
b. excessive grimacing and facial contortion.
c. rounded lips thrust forward in tubular
manner called as Schnauzkrampf ( snout spasm).

8. 5. Expressive movement disorder in mania:
a. Undue cheerfulness and wide expansive
gestures.
b. Emotional lability.
c. Ecstasy – rapt intense look. Patient is
incommunicative and completely absorbed by
intense experiences.
B. DISORDERS OF REACTIVE MOVEMENT:
Reactive movements are immediate automatic
adjustments to new stimuli, as needed in
response to a threat or while attending to
source of a percept.

9. a. startle reflex – in severe anxiety reactive
movements are prompt and excessive.
b. loss of reactive movements in catatonia due
to obstruction, which are carried out in stiff
disjointed manner.
C. DISORDERS OF GOAL DIRECTED MOVEMENTS:
Usually all these movements are carried out
without any deliberate awareness on the part of
the patient. These movements reflect
personality as well as the current mood state of
the subject.

10. a. Psychomotor Retardation :
It is experienced subjectively as difficulty to initiate
and carry out any activity. There is lack of
expression with furrowed eyebrows and downgazed
eye.
b. Blocking or Obstruction ( sperrung ):
It can be defined as irregular stroboscopic
movement in perception, in which the patient
would not be able to initiate the movement
depending upon the will but with the chance factor.
Kleist described that the cardinal feature of the
obstruction is the “reaction at the last moment”. As
the severity increases it gradually ascends to
akinesia and then even to stupor.

11. c. Mannerism :
cardinal feature of mannerism are:
Unusual repetition
Exaggeration of normal and adaptive act
Personal significance
Goal- directed
Mannerism can be found in normal subjects,
abnormal personalities, schizophrenia and
neurological disorders.

12. 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.

13. NON ADAPTIVE MOVEMENTS
• A. SPONTANEOUS:
Spontaneous movements are automatic motion,
balanced by the sympathetic and parasympathetic
nervous systems, and are called involuntary motion.
1. Tics
They are sudden involuntary twitching of small groups of
muscles that are reminiscent of expressive movements
and defensive reflexes. The characteristic feature of tic is
that the movement is usually preceded by an urge to
move, and it can be suppressed for a short time (about
30-60 sec) by voluntary effort. They are rapid, recurrent,
non-rhythmic, stereotyped.

14. • 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

15. 2. Tremor
Tremor is an involuntary, somewhat rhythmic,
muscle contraction and relaxation involving to-and-
fro movements (oscillations or twitching) of one or
more 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 tremors
again can be of two types: postural tremor
(Physiologic tremor, Essential tremor, Drug-induced
tremors) and kinetic tremor (Intention tremor and
Task-specific tremor) .

16. 3. Chorea
is a quick, irregular, and predominantly distal involuntary
movement. The term ‘semi purposive’ has been used to
facilitate its identification. These jerky movements
resemble fragments of expressive or reactive movements.
4. Athetosis
Athetosis is a condition in which the spontaneous
movements are slow, twisting and writhing, which bring
about strange postures of the body, especially of the hands.
The maintained posture is interrupted by relatively slow,
sinuous, purposeless movements that have a tendency to
flow into one another. Choreoathetosis is a movement of
intermediate speed, between the quick, fleeting
movements of chorea and the slower, writhing movements
of athetosis.

17. 5. Parakinesia
Parakinesia is a term used by Kleist (1943) to describe the
occurrence in catatonic schizophrenic patients of motor activity
which is reminiscent of, but somehow different from chorea,
athetosis, and tics. It consists of a continuous irregular
movement of the musculature so that patients with this
symptom grimace, twitch, and jerk continuously. Patients are
usually referred to as parakinetic catatonic, and the older
psychiatrist used to call the behavior as‘clown like.
6. Stereotypy
Stereotypy is a repetitive, seemingly driven, and nonfunctional
motor behavior. They are repeated movements that are regular
(unlike tics) and without any obvious significance (unlike
mannerism). It is required to be distinguished from agitation.
Unlike mannerism, stereotypy is an abnormal, non- adaptive,
non-goal directed and senseless act.

18. • 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.

19.  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 process
of speaking. Seen in cognitive disorders, schizophrenia, and other mental
illness.
Freeman & Gathercole (1966) studied perseveration in
schizophrenia, arteriosclerotic dementia and senile dementia. They
described three types of perseveration:
Compulsive repetition, in which the act is repeated until the
patient receives another instruction. Seen more commonly in
schizophrenia.
Impairment of switching, in which the repetition continues after
the patient has been given a new task. Seen more commonly in dementia.
Ideational perseveration, in which the patient repeats words and
phrases during their reply to a question.

20. • 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 is
repeated.
Palilalia- Patient repeats the perseverated word
with 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.

21.  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.

22.  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 examiner's 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.

23.  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 not
follow the given command and resist any kind of interference.
Active or command negativism: When the patient
not only resists the command given, but also does the
opposite of what is said.
 Gegenhalten or opposition
all passive movements are opposed with same
degree of force as being applied by the examiner.

24. MOTOR SPEECH DISORDER
 Mannerism
only a few words may be mispronounced or there may be
distortion of most of the words.
 Verbal stereotypy
words or phrases are repeated continuously. They may be
spontaneous or set off by a question.
 Verbigeration
one or several sentences or strings of fragemented words are
repeated continuously.
 Wurgstimme
few schizophrenic speak in strange strangled voice
 Verbal perseveration

25.  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 person's 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.

26. 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).

27.  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.

28. 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 psychological
shock. The patient appears as if ‘paralyzed with fear’ and is unable to retreat
from danger – can be terminated by sedation and reassurance.
Hysterical stupor: It emerges as an acute psychogenic reaction to
severe trauma and then becomes a goal-directed reaction. It is presented by
the subject for some gains, although he is not fully aware of his hidden
motivation. It tends to occur in appreciation needing personality.
Catatonic stupor: In this muscle tension is permanently increased or it
varies from time to time and is associated with obstruction. Significant
features are “dead-pan” facial expression, changes in muscle tone, catalepsy,
stereotypies and incontinence of urine.

29.  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 moderately
stressful 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 mild
stress.
Goal-directed reactions: Excitement is part of attention-seeking
behavior. Even during severe excitement, it is usually possible to make contact
with these patients and interrupt the over activity. They seem eager to be
punished and enjoy a good fight.
Excitement in depression: Moderately severe agitated depression:
takes a mechanical form; patient wanders about restlessly and bewail his fate
monotonously though in severe agitation the patient wrings his hands
continuously, sits up in bed, rocks to and fro and laments; sometimes picking
the hair, rubbing the face or pulling the hair; the total picture is one of abject
misery.
Catatonic excitement: In such patients body movements are often
stiff, stilted and violence is usually senseless and purposeless
(Hamilton,1985).

30.  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.

31. 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”.

32.  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.

33.  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.

34. • 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.