Motor disorders

MOTOR DISORDERS

1. MOTOR DISORDERS CHAIRPERSON- PROF. B. N. GANGADHAR PRESENTOR- DR. KARTHIGAI PRIYA

2. MOTOR DISORDERS Subjective motor disorders Objective motor disorders

3. 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

4. Disorders of adaptive movements Disorders of expressive movements Disorders of reactive movements Disorders of goal directed movements

5. DISORDERS OF ADAPTIVE MOVEMENTS DISORDERS OF EXPRESSIVE MOVEMENT Involve face, arms, hands and the upper trunk Varies with emotions

6. In depression- generalized psychomotor retardation , bodily gestures – diminished or absent

7. 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’

8. Veraguth fold – The main fold in upper eyelid is angulated upwards and backwards Described by Otto veraguth Corners of mouth drawn downwards In depression

9. Agitated or anxious depression Patient may be restless or apprehensive talking continuously, Hand wringing , fidgeting, tearing at the clothing

10. 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

11. Schizophrenia (catatonia) expressive movements disordered or scanty stiff expressive face excessive grimacing snout spasm ( schnauzkrampf )

12. Mania – wide expansive gestures Ecstasy or exaltation –rapt intense look, incommunicative

13. 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

14. 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

15. 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

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. C horea 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

23. 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 ( G ervin et al)

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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. d ifferent from schizophasia which is gross thought disorder Wurgstimme - unusual strangled voice or whisper in schizophrenia pts Mannerism- mispronounced or distorting words Echolalia / echologia

30. 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.

31. 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

32. 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

33. 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

34. 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- a cute psychogenic reaction to severe trauma and becomes a goal directed action though pt is not aware of his hidden motivation

35. 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

36. 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

37. 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

38. 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.

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