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MOTOR DISORDERS-2-2.pptx
- 1. MOTOR DISORDERS-2 DISORDERS OFNON ADAPTIVE MOVEMENTS PRESENTER- DR ARAFES RAHIM MODERATOR – DR RAJESH M
- 2. INTRODUCTION DISORDERS OFNON ADAPTIVE MOVEMENTS SPONTANEOUS MOVEMENTS DISPLACEMENT ACTIVITY TICS TREMORS CHOREA STEREOTYPY
- 3. ABNORMAL INDUCEDMOVEMENTS AUTOMATIC OBEDIENCE ECHOLALIA ECHOPRAXIA PERSEVERATION MITGEHEN MITMACHEN GEGENHALTEN NEGATIVISM
- 4. CLASSIFICATION DISORDERS OFADAPTIVE MOVEMENT DISORDERS OF NONADAPTIVE MOVEMENT MOTOR SPEECH DISTURBANCES DISORDERS OF POSTURE ABNORMAL COMPLEX PATTERN OF BEHAVIOUR DRUG INDUCED MOVEMENT DISORDER
- 5. DISORDERS OF NONADAPTIVE 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 Repetitivenongoal 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 maybe 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 involuntarytwitchings 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 canoccur 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 dela 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 Tremorsare 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 ANDACTION 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 Specialtype 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 PHYSIOLOGICTREMORS 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 tremortakes 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 Itis quick,irregular and predominantly distal involuntary movement. Seen in rest and in action. They resemble fragments of expressive or reactive movements.
- 23. In Huntingtonschorea 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 Slowwrithing 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 incatatonia Described by Kleist (1943) Constant motion with grimaces and exaggerated smiles, twitch or jerk continuously Parakinetic catatonia
- 26. ABNORMAL INDUCED MOVEMENTS AUTOMATIC OBEDIENCE PRESERVATION ECHOPRAXIA ECHOLALIA FORCED GRASPING
- 27. MITMACHEN (COOPERATION) MITGEHEN (EXTREME COOPERATION) GEGEHALTEN (OPPOSITION) NEGATIVISM
- 28. AUTOMATIC OBEDIENCE Patient carries out every instruction regardless of consequences. Seen in Catatonia and also in Dementia.
- 29. PERSEVERATION Senselessrepetition 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 Lastsyllable 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 andGathercole 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 repetitionis 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 Patientsimitate 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 Extremeform 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 Accentuationof 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 Mildvariety 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 onMotor 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
- 42. REFERENCE Fish ClinicalPsychopathology, signs and symptoms in psychiatry.
- 43.
Editor's Notes
- #6 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.
- #9 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.
- #10 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
- #12 Tremors can be physiologic or pathologic.
- #15 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
- #21 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
- #24 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.
- #29 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.
- #30 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.
- #31 Both palilalia and logoclonia can occur in organic brain disorders and schizophrenia.
- #35 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.
- #38 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.
- #39 Not obvious when passive movements are carried out very gently and it may appear when the examiner attempts to produce forceful passive movements.
- #40 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.
- #41 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.