32 - Non Catatonic symptoms

Non-Catatonic symptoms:

© SPMM Course similar to thought blocking but occurs while carrying out motor acts. A patient with obstruction suddenly stops a motor act for no reason, without any warning. This may be demonstrated by asking the patient to move a part of his body; the movement is generally well begun, but then stops halfway without any indication. Grimacing refers to the maintenance of odd facial expressions. An odd variant of grimacing is called schnauzkrampf, where the patient cups his lips as if they are spastic (snout spasm). Stupor presents as immobility (usually the extreme opposite of excitement where no activity is noticeable though the patient is able to perceive stimuli). This is akin to akinetic mutism of neurological states. Paradoxically in extreme mania too, stuporous immobility can occur. But it is more common in depression. Catatonic excitement is characterised by extreme apparently non-purposeful hyperactivity, which presents as constant motor unrest. Unlike akathisia, this is often dramatic with no subjective component. Mannerisms: Odd, but purposeful movements (hopping, saluting passers-by or mundane movements). They are also known as idiosyncratic voluntary movements though the patient may claim unawareness. These often have a delusional meaning in schizophrenia. They are different from stereotypes as mannerisms appear as goal-directed movements. Mutism is discussed in detail along with speech disorders. Negativism is an extreme form of opposition – see above. Posturing refers to the maintenance of odd and bizarre postures. These might be spontaneously undertaken or derived from an arrested motor activity e.g. posture with swung arms as if one is frozen when walking. This is maintained despite efforts to be moved. It is also called catalepsy. Psychological Pillow: This is an extreme form of posturing. The patient holds their head several inches above the bed while lying and can maintain this uncomfortable posture for long periods of time. Stereotypes are non-goal directed motor activity (e.g., spinning one's hands, repeated touching, patting, rubbing self). These are seen in catatonia and also in pervasive developmental disorder and severe learning disabilities. Non-Catatonic symptoms: Agitation vs. akathisia: Psychotic agitation is very difficult to distinguish from akathisia secondary to antipsychotics. But such distinction is important, as the latter requires a decrease, not increase, in medications administered. Akathisia has a subjective component of restlessness together with objective evidence of unrest; at times one may have to resort to benzodiazepines when the distinction is unclear Some common mannerisms Tiptoe walking Finger to lip moves (‘shushing’) Clicking sounds during speech Odd robotic speech, without contractions (can not instead of can’t) Shrugging Grimacing Parakinesia (contracting entire facial muscles) Tapping, adjusting, saluting

© SPMM Course though the dose required to treat one may be different from the dose required for the other. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1289895/ Astasia-abasia: Inability to walk, sit or stand upright without any obvious neurological deficits in motor strength and innervations. It is described that some patients with this syndrome cannot balance themselves upright but can run with a bizarre posture. Occurs as a motor conversion disorder. Blepharospasm is a type of focal cranial dystonia that must not be confused with catatonia. Blepharospasm may be seen in Tardive Dyskinesia. It usually begins gradually with excessive blinking. Initially, episodes are triggered by specific stressors, e.g., bright lights, fatigue, distress etc., and disappear with sleep. Concentrating on a specific task (such as watching TV) often decreases the frequency of the spasms. With time, the spasms may become progressively intense, functionally blinding the patient during each episode wherein the eyelids remain vehemently closed for longer periods. Perseveration: This refers to repeatedly same response – either verbal or motor, when different stimuli are delivered (questions or instructions). Irrespective of changes in stimuli that demand variation in responses, the response here remains the same. It is different from Verbigeration (see below) where verbal repetition occurs spontaneously, not just in response to questions or commands. Also note that perseverative responses are goal directed – they intend to answer a question or carry out an instruction, but stereotypes on other hand are not goal directed. It differs from echo phenomenon; the latter is a copying of other person’s responses, not repeating self-responses. Tics: These are sudden involuntary (but temporarily suppressible) jerking movements often seen in facial and vocal musculatures though it can affect any skeletal muscle group in the body. They typically have a waxing and waning course, worsening with low mood and fatigue and not seen in sleep. Some tics may appear as coordinated complex acts such as grunting, uttering syllables that may amount to coprolalia (obscenities) or echophenomenon. Tics seen in Tourette’s differ from other simple tics in that they are preceded by a palpable urge or prodromal sensation before the motor act. Tics have been conceived to share the pathophysiology of obsessions. Verbigeration: Repetition of phrases or sentences. This occurs spontaneously and without any goal. This should not be confused with echolalia. This is not catatonia. Stereotypy Mannerism Meaningless motor expression

Behaviour has a special purpose or meaning

Often repetitive

Not particularly repetitive

e.g. Repeated hand-wringing, or rocking movements e.g. wearing black goggles all the time, Patient cannot explain the behaviour At times, patient can come up with some explanation that may / may not be delusional