Motor disorders

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.