motor disorders
DESCRIPTION
MOTOR DISORDERSTRANSCRIPT
MOTOR DISORDERSCHAIRPERSON- PROF. B. N. GANGADHAR
PRESENTOR- DR. KARTHIGAI PRIYA
MOTOR DISORDERS
•Subjective motor disorders
•Objective motor disorders
CLASSIFICATION
DISORDERS OF ADAPTIVE MOVEMENTS
DISORDERS OF NON ADAPTIVE MOVEMENTS
MOTOR SPEECH DISTURBANCES
DISORDERS OF POSTURE
ABNORMAL COMPLEX PATTERNS OF BEHAVIOUR
DRUG INDUCED MOVEMENT DISORDERS
DISORDERS OF ADAPTIVE MOVEMENTS
• Disorders of expressive movements
• Disorders of reactive movements
• Disorders of goal directed movements
DISORDERS OF ADAPTIVE MOVEMENTS
1. DISORDERS OF EXPRESSIVE MOVEMENT
Involve face, arms, hands and
the upper trunk
Varies with emotions
• In depression- generalized psychomotor retardation ,
bodily gestures – diminished or absent
• Omega sign / omega melancholicum – Wrinkling of the skin
above the nose and between the eyebrows that resembles
the greek letter ‘omega’ produced by the excessive action of
corrugator muscle
• First described by Charles Darwin in ‘The expressions of the
emotions in man and animals’
• Veraguth fold – The main fold in upper eyelid is angulated upwards
and backwards
• Described by Otto veraguth
• Corners of mouth drawn downwards
• In depression
• Agitated or anxious depression
Patient may be restless or apprehensive
talking continuously, Hand wringing ,
fidgeting, tearing at the clothing
AGITATION
• severe anxiety with motor restlessness
• unpleasant state of extreme arousal
• Can come suddenly or over a period of time
• Can occur in anxiety, depression, dementia, schizophrenia, mania,
drug intoxication or withdrawal, medical illnesses
• D.D- Akathisia, excitement
• Schizophrenia (catatonia)
expressive movements disordered or scanty
stiff expressive face
excessive grimacing
snout spasm
(schnauzkrampf)
• Mania – wide expansive gestures
• Ecstasy or exaltation –rapt intense look, incommunicative
DISORDERS OF REACTIVE MOVEMENTS
• Immediate automatic adjustments to new stimuli
• Anxiety states- excessive reactive movements
• Reactive movements are affected by obstruction in
catatonia or stupor
DISORDERS OF GOAL DIRECTED MOVEMENTS
• voluntary movements that are organized around behavioral
goals, environmental context, and task specificity, as
distinguished from reflexive movements.
• Reflect both the personality and their present mood state
• In Depression - actions become more difficult to initiate
and carry out
• In mania - increased involvement in goal directed activities
especially pleasurable
• overall pattern of behavior not consistent
• In catatonia, blocking or obstruction (sperrung) gives rise to
an irregular hindrance to motor activity.
• Retardation vs obstruction
• Stupor occurs with severe grades of obstruction
• Mannerisms
• Unusual repeated performances of a goal directed action or the
maintenance of an unusual modification of an adaptive posture
• The strange use of words, high flown expressions and movements
and postures out of keeping with the total situation
• Bizarreries- grotesque distorted movements and postures in which
no goal or aim can be seen.
DISORDERS OF NON-ADAPTIVE MOVEMENTS
• Spontaneous movements – motor habits that are not goal oriented like
scratching of the head , clearing the throat
• Displacement activity – the normal motor habits occurring when the
individual is frustrated or is uncertain about their choice of behaviour
pattern
STEREOTYPY
Repetitive , ritualistic movement , posture or utterance
Stereotypies may be simple movements such as body rocking, or
complex, such as self-caressing, crossing and uncrossing of legs, and
marching in place.
It may be possible to discern the remnants of a goal directed
movement in stereotypy
They are found in people with Schizophrenia, intellectual disabilities,
autism spectrum disorders, tardive dyskinesia and stereotypic
movement disorder
PARAKINESIA
• Seen in catatonia ,Described by Kleist(1943)
• Continuous . Irregular movement of the musculature
• Patients grimace , twitch or jerk continuously
• Parakinetic catatonia , a type of schizophrenia–Karl Leonhard
INVOLUNTARY MOVEMENTS
• Tics - sudden repetitive non rhythmic motor movement or
vocalization involving discrete muscle groups
• Commonly the face is affected . E.g. Blinking , clearing the
throat, twitching of the shoulders
• They can occur after encephalitis or indicate the onset of
Gilles de la Tourette syndrome
• Psychogenically determined motor habits
Tremors
• 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
• Static / intentional / postural tremors
• Seen in anxiety disorders, conversion reaction , drug withdrawal,
parkinsonism, thyrotoxicosis
• Organic tremors can vary in intensity from day to day are made worse
by emotional disturbances
Chorea
- brief, semi-directed, irregular movements that are not repetitive or
rhythmic, but appear to flow from one muscle to the next.
- Often associated with athetosis
- Causes- Huntingtons, Sydenham chorea , drug induced, pregnancy
Athetosis
- Slow writhing movements involving fingers, hands, toes, feet, which
bring about strange postures of the body
- Can be seen in catatonia
Spasmodic torticollis
There is a spasm of the neck muscles, especially the
sternomastoid, which pulls the head towards the same side and twists
the face in the opposite direction
Involuntary movements are associated with antipsychotic medication
They are also relatively common in drug naïve patients
11.4 % of drug naive schizophrenia pts had orofacial dyskinetic
movements and 7.4% had tardive dyskinesia (Gervin et al)
ABNORMAL INDUCED MOVEMENTS
Automatic obedience
Patient carries out every instruction regardless of the consequence (Hamilton
1985)
Echopraxia
Patients imitate simple actions of examiners
Completely automatic, echopraxia to mirror images & voluntary echopraxia
Echolalia
patient echoes a part or whole of what has been said to them
Mitmachen (cooperation )
Body can be put into any position without any resistance on
the part of the patient, although they have been instructed to
resist all movements
Mitgehen very extreme form of cooperation
Patient moves their body in the direction
of the slightest pressure on the part of the examiner
Anglepoise lamp sign(Hamilton)
Gegenhalten or opposition
patient opposes all passive movements
with same degree of force as examiner
Negativism
apparently motiveless resistance to all interference and may or may not be
associated with outspoken defensive attitude
may be active or passive
Ambitendency
patient makes a series of tentative movements that do not reach the desired
goal when they are expected to carry out a voluntary action
patient appears to be in conflict about moving their body and this presence of
opposing tendencies to action may be regarded as ambivalence
Perseveration
senseless repetition of a goal directed action that has already
served its purpose
Freeman & Gothercole (1966) described 3 types
1. compulsive repetition
2. Impairment of switching
3. Ideational perseveration
Logoclonia and pallilalia (Hamilton)
Stereotypy is spontaneous and perseveration is induced
Forced grasping
Despite frequent instructions not to touch the examiners hands
the patient continues to do so.
Grasp reflex
patient automatically grasps all objects placed in his hand
Magnet reaction
If the examiner rapidly touches the palm and steadily withdraws
his fingers the patients hand may follow the examiner’s finger like a
piece of iron following a magnet.
Occurs in catatonia and organic brain disorders
MOTOR SPEECH DISTURBANCES
Verbal stereotypy – words or phrases repeated continuously , spontaneous or set
off by a question
Verbigeration – compulsive repetition of seemingly meaningless words, phrases or
sentences without regard to stimulus.
different from schizophasia which is gross thought disorder
Wurgstimme - unusual strangled voice or whisper in schizophrenia pts
Mannerism- mispronounced or distorting words
Echolalia /echologia
DISORDERS OF POSTURE
• Manneristic posture-odd stilted posture that is an
exaggeration of a normal posture not rigidly preserved.
• Stereotyped posture- abnormal and non-adaptive posture
that is rigidly maintained.
• Psychological pillow- pts lie with their head off the pillow
and maintains this posture for hours.
Posturing or preservation of posture
• The patient tends to maintain for long periods postures that have arisen fortuitously or
which have been imposed by the examiner
Catalepsy (nervous condition charecterised by rigidity , posturing and decreased
sensitivity to pain)
Waxy flexibility
• There is a feeling of plastic resistance as the examiner moves the patients body which
resembles the bending of a soft wax rod and when the passive movement stops the final
posture is preserved
ABNORMAL COMPLEX PATTERNS OF BEHAVIOUR
Non goal directed
Stupor –state of more or less complete loss of activity where there is no reaction
to external stimuli
• Extreme form of hypokinesia and mute
• May occur in severe psychological shock , dissociative states ,depression ,
psychosis, catatonia and organic brain disease like epilepsy
• Space occupying lesions affecting the third ventricle ,thalamus and midbrain –
akinetic mutism –eyes open and pt appears to be alert
Catatonic stupor
• Pure akinesia
• muscle tension is markedly increased and patient feels like a block of
wood
• Snout spasm , psychological pillow is sometimes seen
• Face is usually stiff and devoid of expression –deadpan expression
• No emotional response to affect laden questions
• Response to painful stimuli is absent
• Double incontinence may occur
Depressive stupor
• Depressed look
• Facial expression is of anxiety and bewilderment
• Catalepsy, obstruction , stereotypies, changes in muscle tone and
incontinence doesn’t occur
Dissociative stupor-
acute psychogenic reaction to severe trauma and becomes a goal
directed action though pt is not aware of his hidden motivation
Excitement
• Opposite of stupor, but can occur in the same mental illnesses
• Extreme hyperactivity. Constant motor unrest which is apparently non purposeful
• Psychogenic excitements may be acute reactions or goal directed reactions
• Goal directed may be seen in predisposed subjects on exposure to stressors
• Commonly seen in mania and catatonic schizophrenia
• In manic excitement patient is cheerful or irritable, restless and interfering with
flight of ideas
• In catatonic excitement face is deadpan and movements are often stiff and stilted
and violence is usually senseless and purposeless
• In delirium there may be ill directed over activity and are extremely frightened at
times
• Pathological drunkenness (mania a potu)
• Excitement with senseless violence after the patient has drunk a small quantity of
alcohol
Goal directed abnormal patterns of behaviour
--occur nearly in all mental illnesses
Aggressive behaviour
Compulsive rituals
Suicidal or self injurious behaviour
Disinhibited behaviour
Wandering behaviour or fugue
MOVEMENT DISORDERS ASSOCIATED WITH ANTIPSYCHOTIC MEDICATION
• Dystonia –acute or chronic
syndrome of sustained muscle contractions, frequently causing
twisting and repetitive movements or abnormal postures.
• Akathisia – A subjective feeling of restlessness accompanied by
motor stereotypies.
• Tardive dyskinesia –delayed effect of antipsychotics .usually after 6
months.
Characterized by abnormal involuntary movements irregular
choreoathetoid movements of the muscles of the head, limbs and trunk.