movement disorders (Psychiatry)

1. GUIDE – DR. RAMGHULAM RAZDAN SIR
PROFF. AND HEAD OF DEPARTMENT
DEPARTMENT OF PSYCHIATRY
PRESENTER-DR RASHMI DHAKAD
MOTOR DISORDER

2. INTRODUCTION
Motor behaviors are the coordinated patterns of activities to
facilitate the daily living.
All severe psychiatric conditions are associated with changes in
motor functioning.
Changes can be subtle and non-specific, limited to restlessness
that suggests anxiety, or dramatic and diagnostic, such as the
classic postures indicating catatonia.
These are divided into objective motor disorder and subjective
motor disorder.

3. Classification of Disorders of movement (Hamilton, 1985)
 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 of behavior
b. Goal-directed abnormal patterns of behavior
 Movement disorders associated with antipsychotic medication

4. DISORDERS OF ADAPTIVE
MOVEMENTS
DISORDERS OF EXPRESSIVE MOVEMENT
The extent of expressive movement
varies with the emotion.
Expressions in psychiatric disorders
range from dysphoria to ecstasy.
Two major conditions under
psychiatric disorders are
Schizophrenia and Mood disorders.

5. MOOD DISORDERS
In mania, expressive
movements are exaggerated.
Emotional lability
In ecstasy, psychomotor
activity decreases.

6. DEPRESSION
Patients with depression
tend to have a limited range
of expressive movements.
Omega sign: The occurrence
of a fold like the omega in the
forehead above the root of the
nose produced by the
excessive action of the
corrugator muscle.

7. Veraguth 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 fold

8. SCHIZOPHRENIA
Stiff expressionless face and the
expressive movements of the
body are scanty
Snout spasm (Schnauzkrampf),
is a disorder of expression, and is
best regarded as stereotyped
posture in which “pouting of lips
to bring them closer to nose” is
seen.

9. 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.
Get affected in the disturbances of
affect and other neurotic conditions
too like disorders under anxiety
spectrum

10. DISORDERS OF GOAL DIRECTED
MOVEMENT
These movements are intentional purposeful movement
which is called voluntary movement.
It can be categorized under following heads:
Psychomotor retardation
Obstruction (Blocking or Sperrung)
Mannerism

11. Psychomotor Retardation: It comprises a
slowing down of thought and a reduction of
physical movements in an individual.
It occurs in depressive illness mainly.
May lead to stupor.

12. OBSTRUCTION
Also known as Blocking or Sperrung
Gives rise to an irregular hindrance to motor or
psychic activity.
Kleist described that the cardinal feature of the
obstruction is the “reaction at the last moment”.
With increasing severity can lead to akinesia
and stupor.

13. “Psychomotor retardation has
been compared with the
uniform slowing down of a
vehicle produced by the
steady application of a
brake, while obstruction has
been compared with the
effect of putting a rod
between the spokes of a
moving wheel.”

14. MANNERISM
Mannerisms are odd, stylized
movements, usually specific to
the subject and sometimes
apparently suggestive of special
meaning or purpose.
Example are Saluting, holding
hands as if they were handguns,
Peculiarities in dressing, hair
style etc

15. DISORDER OF NON-ADAPTIVE
MOVEMENT
Spontaneous movements
Stereotypy
Abnormal induced movements
Echophenomenon
Perseveration
Automatic Obedience
Mitmachen & Mitgehen
Forced grasping
Magnet reaction
Gegenhalten
Negativism
Ambitendency

16. Spontaneous movements are automatic motion,
balanced by the sympathetic and parasympathetic
nervous systems, and are called involuntary motion.
These actions have obviously been goal-directed at
some time, but have since become spontaneous and
not directed towards any goal.

17. Tic is a brief movement that is generally repeated in
space (same muscle groups) but is irregular in times.
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
Motor and vocal tics may be simple (involving only a few
muscles or simple sounds) or complex.

18. Tremor is a repetitive rhythmic
movement that is consistent in
time and space.
Tremor is an involuntary
somewhat rhythmic, muscle
contraction and relaxation
involving to-and-fro movements
(oscillations or twitching) of one
or more body parts.

19. Chorea is a quick,
irregular, and
predominantly distal
involuntary movement.
The term ‘semi purposive’
has been used to facilitate
its identification.

20. 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.
Parakinesia, term used by Kleist (1943) is a continuous
irregular movement of the musculature so that patients
with this symptom grimace, twitch, and jerk
continuously. Patients usually referred as parakinetic
catatonic, and the older psychiatrist used to call the
behavior as a ‘clown like’(Hamilton,1985)

23. 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)
These movements do not appear to have any special
significance .

24. ABNORMAL INDUCED MOVEMENTS
In the elicitation of all types of
behavior of abnormal
compliance, the patient must be
made to understand that he is
expected to resist the examiner’s
efforts to move him.

25. Due to undue compliance on the part of the
patient :
Automatic Obedience (also called command
automatism) is an exaggerated cooperation with
examiner’s request, or repeated movements that
are requested once
How to examine: Reach into pocket and state,
‘stick out your tongue, I want to stick pin into it’.
(Bush et al, 1996)

26. 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.
Patients do not know why they make these movements and
they usually give a silly or inadequate reason for it, denying
their illness.
How to examine: Examiner scratches head in exaggerated
manner while conversing with the patient. (Bush et al, 1996)

27. Echolalia is a pathological, parrot like, and apparently senseless
repetition of a word or a phrase just spoken.
There are two types of echolalia namely:
Immediate echolalia : It appears to tap into the person's short-
term memory for auditory input.
Delayed echolalia: It 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.

28. Echologia (Kleist, 1943): The patient replies to
questions by echoing the content of the questions in
different words.
Perseveration is a senseless repetition of a goal-
directed action, which has already served its purpose
(Hamilton, 1985).
Freeman & Gathercole (1966) studied perseveration in
schizophrenia, arteriosclerotic dementia and senile
dementia. They described three types of perseveration:

29. Compulsive repetition
Impairment of switching
Ideational perseveration
Perseveration in coarse brain disease:
• Logoclonia The last syllable of the last word is repeated.
• Palilalia Patient repeats the perseverated word with
increasing frequency.

30. Mitmachen (cooperation)
Mitgehen (going along with) also known as the
“anglepoise effect” or “angle poise lamp sign”
How to examine: The examiner puts his forefinger
under the patient’s arm and raises gently after
stating ‘do not let me raise your arm’, whereupon the
arm moves upwards in the direction of the pressure.

31. Forced grasping is a phenomenon in which the patient
forcibly and repeatedly grasps the hands of an examiner
when offered
Magnet reaction
Negativism
 Passive negativism
Active or command negativism
How to examine: The examiner takes the patient hand
and arm and moves the patient’s arm horizontally back
and forth, with varying degrees of forces

32. Ambitendency is a phenomenon in which the patient
alternates between resistance to and cooperation with the
examiner’s instructions
How to examine:
The examiner offers a hand, as if to shake hands, and
firmly tells the patient “Don’t shake my hand. I don’t want
you to shake it.” The patient moves their hand towards
the examiner’s hand, stops, starts moving the hand, stops,
and so on, until the hand finally comes to rest without
touching the examiner’s hand or at maximum lightly
touching the examiner’s hand (Bush et al, 1996; Fink &
Taylor, 2003).

33. DISORDERS 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
Perseveration of posture The patient
persists with a particular movement that has
lost its initial significance.

34. Psychological pillow:
A stereotyped posture, in
which the supine patient
lies with head and
shoulders raised as if
resting on a pillow.

35. Posturing Patient is able to
maintain the same posture for long
periods
Waxy flexibility The examiner is
able to position the patient in what
would be highly uncomfortable
postures, which are maintained for
a considerable period of time
Catalepsy It is a condition in
which a person maintains the body
position in which he is placed

36. How to examine:
Patient must be told that they are not obliged to leave their
body in the position in which it is put by the examiner.
Put the patient’s arm in a comfortable position, and if this
is maintained, the arm is put into a series of unusual
positions so that finally the patient will preserve very
strange postures.
If gentle passive movements fail to elicit catalepsy, it can
sometimes be evoked by moving the arm or limb more
firmly into a strange position.

37. ABNORMAL COMPLEX PATTERNS OF
BEHAVIOR
Non- goal directed
Stupor
Psychogenic stupor
Hysterical stupor
Catatonic stupor
Excitement
Acute reaction
Catatonic excitement
Excitement in depression
Goal directed
Compulsive rituals
Brutal and aggressive
behavior
Disinhibition
Dissociative fugue

38. • 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 (Fink & Taylor,2003).
 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.
 Catatonic stupor: In this muscle tension is permanently
increased or it varies from time to time and is associated with
obstruction.

39. • Excitement: It can characterize as an extreme hyperactivity, constant
motor unrest which is apparently non-purposeful
Acute reactions: Predisposed subjects may react to moderately
stressful situations with senseless violence.
Goal-directed reactions: Excitement is part of attention-seeking
behavior.
Excitement in depression: Moderately severe agitated depression:
takes a mechanical form; patient wanders about restlessly and bewail his
fate monotonously
Catatonic excitement: In such patients body movements are often
stiff, stilted and violence is usually senseless and purposeless

40. a) Goal-directed abnormal patterns of behavior: Abnormal patterns of behavior
of this type occur in nearly all psychiatric syndromes:
 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.
 ‘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.
 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.

41. MOVEMENT DISORDER ASSOCIATED
WITH ANTIPSYCHOTIC MEDICATION
Drug induced dyskinesia

42. Acute dystonia
Acute and tardive
akathisia
Tardive dyskinesia
Tardive tremor
Tardive dystonia
Tardive tourettism
Tardive myoclonus
Neuroleptic malignant
syndrome
Serotonin syndrome
Rabbit syndrome

43. • Acute dystonia: Acute dystonic reaction is sustained, repetitive,
patterned, muscle spasm resulting in twisting, squeezing, pulling,
and often painful posturing.
• 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.
• Tardive dyskinesia: It is a distortion of voluntary movements with
involuntary muscular activity.

44. • 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 Dystonia: It is a persistent dystonic movement disorder and
therefore it differs from acute transient dystonic reaction
• Tardive tourettism: Gilles de la Tourette syndrome is a
neurobehavioral disorder characterized by motor and phonic tics and a
variety of behavioral problems
• Tardive Myoclonus: Myoclonus, a jerk- like contraction of muscle
group may be rhythmic or arrhythmic, arising from cortical,
subcortical, and spinal cord structures.

45. Neuroleptic Malignant Syndrome is believed to be a consequence
of impaired hypothalamic and striatal dopamine transmission or
sudden withdrawal from dopamine therapy
• 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.
• Rabbit Syndrome: The rabbit syndrome is another neuroleptic drug
induced disorder.. It was first described in 1972 as “perioral
muscular movements strikingly imitating the rapid, chewing-like
movements of a rabbit’s mouth

47. MOVEMENT DISORDERS DIAGNOSED IN
CHILDHOOD AND ADOLESENCE
• Developmental coordination disorder
• Repetitive behaviors
Stereotype
Compulsive behaviour
Sameness
Ritualistic behaviour
Restricted behavior
Self injury

48. • Tic disorder
Tourette’s disorder
Chronic motor or vocal tic disorder
Transient tic disorder
Tic disorder NOS
• Stereotypic movement disorder

49. PSYCHOLOGICAL EXPLANATIONS OF
MOTOR DIORDERS
• Conversion disorder: the physical symptom(s)
serve as the resolution for the conflict.
• Stereotypy: a way to release tension or
express frustration, that they communicate a
need for attention or reinforcement.

50. • Tourette’s syndrome: possible outcomes of narcissistic, repressed
childhood sexuality
• Non epileptic seizures: Viewed as a result of intrinsic emotional problem or
to internalized conflicts.
• Compulsive acts: It arises when unacceptable wishes and impulses coming
from the id are only partially repressed, provoking anxiety and to reduce this,
the individual engages in compulsive behavior
• Catatonia: viewed as a fear response, akin to the animal
defense strategy of tonic immobility.

51. CULTURAL VARIANTS OF MOTOR
DISORDERS

52. • Ganser’s syndrome:characterized by the individual mimicking behavior they
think are typical of a psychosis, by providing nonsensical or wrong answers to
questions, and doing things incorrectly.
• Latah:Latah, reported in Arcadian Maine but linked to Malaysia, is
characterized by echolalia, echopraxia, coprolalia and automatic obedience
within a manic.
• Amok:Associated with south-east Asia,characterized by sudden, frenzied,
violent, and often murderous attacks on strangers in public settings with
multiple victims
• Lycanthropy:associated with eastern European lore of wolf-men, is the
combination of motor disorders with the delusional belief of being changed into
an animal due to the influence of the devil.

53. REFERENCES
• Sadock. B.J., Sadock.V.A. (2007). Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry, 10th ed. New York:Lippincott Williams & Wilkins.
• Taylor, M.A. & Vaidya, N.A. (2009). Descriptive Psychopathology: The Signs and
Symptoms of Behavioral Disorders. Cambridge: Cambridge University Press.
•
• Joseph, A.B., Young, R.R. (1999). Movement Disorders in Neurology and
Neuropsychiatry. 2nd ed. Malden, MA: Blackwell Science.
• . casey p. fish's clinical psychopathology. 3rd ed. mumbai, india: suketu p.
kothari; 2007.
• (
.
*Hamilton, M. (1984). Fish’s Schizophrenia (3rd Ed). Oxford: John Wright & Sons Ltd .