31 - Catatonic symptoms

Catatonic symptoms:

© SPMM Course 7. Motor symptoms Fish classified motor symptoms into a. Abnormal spontaneous movements: Tremors, Tics, chorea, athetosis and stereotypy noted in autistic spectrum disorders, hemi-ballismus, etc. b. Abnormal induced movement: Perseveration, automatic obedience, echo phenomenon and other catatonic signs Catatonic symptoms: Fink & Taylor have argued to include catatonia as a separate taxonomy in psychiatric nosology. Catatonia is decreasing in frequency in its classical form, largely due to early diagnosis, treatment and deinstitutionalisation. Catatonia is defined as rigidity during involuntary movements while volitional movement is carried out normally. Note that in neurological spasticity the tone is increased irrespective of passive or active movements. A patient with catatonia can use the affected limb or muscle group when needed with completely normal tone – for example, running out when there is a fire. Catatonia persists in sleep and can continue for weeks without improvement. Catatonia is mostly seen in advanced primary mood or psychotic illnesses. Among inpatients with catatonic presentation, 25 to 50 percent are related to mood disorders and approximately 10 percent are associated with schizophrenia. Catatonia results in both speech and motor disturbances.

Ambitendence: Here a schizophrenic patient brings the spoon to his mouth dozens of times but never completes the act. In ambitendency, the patient makes a series of tentative, opposing alternate movements that do not reach the intended goal. This becomes evident when the patient is asked to carry out a motor act e.g. asking the patient to show his tongue will elicit repeated protrusion and retraction of tongue as if Prominent catatonic symptoms Non-catatonic motor symptoms seen in psychiatry Ambitendence Akathisia Automatic Obedience Perseveration Catalepsy Blepharospasm Echo-phenomenon Dystonia Gegenhalten Tardive dyskinesia Grimacing Tics Mannerism Astasia-abasia Mutism Chorea* Negativism Tremors* Posturing Athetosis* Stereotypy Hemiballismus* Stuporous immobility/excitement

• Mostly neurological cause

© SPMM Course the patient is undecided about showing his tongue. (Note ambivalence: Inability to make a decision – dilemma of the volitional faculty. It may also appear as affective ambivalence- e.g., To love and hate the same person at the same time or intellectual ambivalence-E.g. Assertion and denial of the same idea. This is not a catatonic symptom.) Automatic obedience: Exaggerated cooperation with examiner’s request or spontaneous continuation of movement requested. To demonstrate this, the examiner must ask the patient not to cooperate, but still the patient will carry out motor instructions. In days where ethics did not hamper research, Kraepelin demonstrated automatic obedience by pinching his patient’s tongue with a pin every time he protruded it; but the patient continued to obey Kraeplin’s commands in spite of this! Mitmachen and mitgehen are closely related to automatic obedience:  Mitmachen can be considered as a mildest form of automatic obedience where despite requests to resist manipulation, the patient yields himself to be placed in abnormal postures.  Mitgehen or “Anglepoise lamp” sign: The patient yields to slightest of pressures, without much resistance, similar to an angle poise lamp that bends easily. This happens even if the patient is instructed to resist any manipulation. This may be a milder form of automatic obedience. It is also called ‘magnet reaction’ as the patient may even follow the examiner around the room with light touch as if pulled by a magnet. Catalepsy or Waxy flexibility: Also called flexibilitas cerea. Here the patient shows wax-like plastic ‘mouldable’ quality. His limbs can be moved by the examiner to occupy certain postures, which are then maintained, even if these are uncomfortable and bizarre. Differentiating this from mitmachen / mitgehen (Automatic Obedience)  Unlike flexibilitas cerea, there is an explicit request to resist manipulation in mitmachen  The arm comes back to resting position when released by the examiner in mitmachen, but not in catalepsy  Unlike mitgehen, the manipulation is not gentle with finger tip but full and complete in catalepsy Echo-phenomenon: This is seen in catatonia, Latah (a culture-bound disorder) and also in Tourette’s syndrome. Echopraxia: mimicking examiner’s movements Echolalia: mimicking examiner’s speech. In Gegenhalten (aka paratonia or opposition) there is a resistance to passive movements with the proportional strength to the increase of muscle tone which seems to be voluntarily controlled by the patient. Patients with negativism resist or oppose all passive movements attempted by the examiner. This is an extreme form of opposition where apparently motiveless resistance to all interference is found. Negativism can be a frustrating symptom especially for carers involved in offering nursing assistance to the patient. The catatonic symptom of blocking or obstruction (or Sperrung) refers to a phenomenon