Appearance and behaviour

Question 1

Distractibility

Answer 1

inability to screen out irrelevant stimuli, such as noises outside the room

Think - ADHD, mania, organic mental disorders “ delerium”

Question 2

Internal preoccupation

Answer 2

episodic inattentiveness to the interviewer whenever the patient becomes distracted by intrusive thoughts or hallucinations

• severe depression
• psychosis

Question 3

Resistance

Answer 3

conscious or unconscious attempt to withhold information or affect from the examiner

Question 4

Splitting

Answer 4

the inability of a person to recognise good and bad features simultaneously in another individual ( or institution)

• BPD

Question 5

Akathisia

Answer 5

Feeling of motoric restlessness -
particularly the legs, - usually a side effect of neuroleptic medication (ie. antipsychotics)

It is a subjective experience and its diagnosis is therefore based on patients reports. However may appear to tremble nervously, shake their legs ( even when sitting) or keep getting up to walk around

Attempts to remain still are likely to increase discomfort. It should be differentiated from anxiety, psychomotor agitation , agitated depression, and restless legs syndrome

Question 6

Abulia

Answer 6

Decreased activity due to a lack of ability or power to execute action despite a desire to do so.

It is often associated with slowing or increased latency of mentation. described as inert, uncaring, and undriven- may resemble depression but abulic patiens wont cry or report feeling sad.

Most often seen in Schizophrenic or ABI (frontal/basal ganglia)

• slow in performing simple cognitive tasks

Question 7

Agitation

Answer 7

emotionally distressed, cannot sit still or attend and gives evidence of heightened tension

acute grief, generalised anxiety, heart or thyroid disease, medical crisis, drug intoxication or withdrawal, cognitive dysfunction, mania or psychosis

Question 8

Aggression

Answer 8

Behaviour that reflect rage, hostility and the potential for physical or verbal destructiveness.

It is the expression of negative affect meant to assault, harm or manipulate another person in some way

May be planned and/or due to poor impulse control

Frontal lobe impaired persons in part related to an inability to empathise with others,

Demented/delirious/psychotic patients - erroneously perceive other persons as intending to harm them

Conduct disorder /BPD/Antisocial - always volitional and planned

Question 9

Assertiveness

Answer 9

socially appropriate limit setting and self definition

Question 10

Akinesia

Answer 10

A marked reduction in accessory motor activity (eg. arms swinging while walking) and in normal automatic movements (eg. blinking, swallowing, periodic postural adjustment).

There may be associated slowing of mentation (abulia)

Associated with psychotic states, extreme depression, catatonia, epilepsy and movement disorders such as parkinsonism ( including that induced by antipsychotic drugs). Lesions of the supplementary motor cortex and hydrocephalus can produce akinesia and mutism.

• differentiate it from paralysis

Question 11

Apathy

Answer 11

a lack of emotions or desire, a feeling of uninvolvement, or not caring.

The outward manifestation of apathy may be confused with abulia

Apathy occurs most often in depression and schizophrenia

Question 12

Athetoid movements

Answer 12

Abnormal movements that are slow, writhing, involuntary and involving the extremeties (eg. fingers, hands and sometimes toes and tongue)

often described as “snakelike”

https://www.youtube.com/watch?v=J_wIDm1_ax4

Question 13

Automatic movements (automatisms)

Answer 13

Involuntary movements that occur in the setting of altered consciousness also termed automatisms.

May occur in psychotic states including catatonia and in hysterical fugue states, but are most suggestive of complex partial or absence seizures. These movements vary widely in character and complexity from bizarre, purposeless movements to complex behaviours

Common epileptic automatisms - lip smacking and swallowing ( complex partial seizures) and rhythmic rapid eye blinking ( absence seizures)

Question 14

Bradykinesia

Answer 14

slowing of motor activity as thought one is in slow motion

Common in EPSE - parkinsonism, schizophrenia, major depression

Question 15

Catalepsy

Answer 15

maintenance of certain bodily positions or postures for prolonged periods of time

often associated with catatonic states such as schizophrenia

Question 16

Cataplexy

Answer 16

A temporary state of sudden involuntary muscle relaxation causing loss of postural muscle tone, in the setting of intact consciousness.

Causes: falling down to only one eyelid closure

Occurs with narcolepsy and is related to REM sleep that abnormally intrude s into wakefullness. It is often precipitated by laughter, fright, or emotional stress.

It is not in itself evidence of a major psychiatric disorder

Question 17

Catatonia

Answer 17

Severe psychotic disturbance of motor function. It is usually manifested by markedly decreased activity but may entail hyperactivity ( catatonic excitement)

The limbs are either rigid or flexible when moved passibely by the examiner. patients may be echopraxic and are mute or echolalic. Automatisms and extreme braykinea can occur as well as grimacing and staring. Catatonic patients may be excessively excited underneath the emotionally unresponsive and motorically statuesque exterior, the may become combative.

Relatively rare, seen in SCZ, BPD, depression and other psychosis

Ddx: partial complex seizures, viral encephalitis, severe parkinsonism, NMS, delirium, lesions of mesial frontal regions, and neurosyphilis

Question 18

Cogwheel rigidity

Answer 18

involuntary resistance to passive flexion/extension and pronation/supination or rotational movements around a joint

Found as EPSE/parkinsons

Not lead pipe rigidity - extreme stiffness but no ratcheting

Question 19

Choreiform movements

Answer 19

irregular, involuntary movements of face, limb or trunk muscles which are faster, jerkier and more discrete than athetoid movements

They reflect basal ganglia dysfunction and can be a manifestation of basal ganglia infarction, tumours or calcifcation. They can occur concurrently with athetoid movements. Hemiballismus is related but more extreme

They are seen in Tardive dyskinesia, Parkinsons disease, Huntingtons disease sydnehams chorea , advanced age and toxicity ( lithium, amphetamines, phenytoin, estrogens, dopamine agonists)

Question 20

Coma

Answer 20

profound unconsciousness with loss of voluntary activity and communication

appears to be asleep, although they cannot be aroused
- due to severe bihemispheric or brainstem reticular formation dysfunction

Must be differentiated from an hysterical condition, locked in syndrome - pontine tegmental lesions ( patient is awake and aware but unable to activate muscles other than those controlling vertical eye movements and/or eye closure

Question 21

Compulsion

Answer 21

Unwanted, ego-dystonic impulse to perform certain motor behaviours. The patient usually realises that the behaviour is unreasonable, but can suppress it only temporarily and at the expense of increasing anxiety

Common: washing/checking
- associated with obsessions

Question 22

Disinhibited behaviour

Answer 22

poor self control or loss of the capacity to resist unacceptable impulses

Refers to characteristic and socially inappropriate speech and behaviour - severe dysfunction of frontal lobes
- SCZ, ethanol intoxication, exaggerated inappropriate rudeness, candor, lewdness, profanity, jocularity, sexual behaviour, preoccupation, public undressing - childish joking ( witzelsucht)

Question 23

Dystonia

Answer 23

involuntary INCREASED tone in a muscle or group of muscles that occurs rarely in parkinsonism and more frequently as an EPSE of antipsychotics

Potential dangerous form is dystonia - laryngospasm as it threatens airways or unilateral spasm of the Sternocleidomastoid (torticollis),
Eyeballs rolling upward, accompanied by extension of the neck ( oculogyric crisis)
bending over backward such that the back of the head approaches the legs ( opisthotonus)

Question 24

Echopraxia

Answer 24

Involuntary repetition and imitation of another persons movements inappropriate to the situation.

Seen in catatonia, tic disorders and partial complex seizures, frontal lobe damage, dementias

Question 25

Extrapyramidal side effects (EPSE)

Answer 25

The pyramidal tracts of the LOWER brainstem ( medulla oblongata) contain fibers of the corticospinal tract - axon of the upper motor neurons of the voluntary motor pathway.

EPSE = all other (involuntary) central neural structures and pathways subserving movement, tone and posture
- Extrapyramidal system = movements of BRAINSTEM, CEREBELLUM and BASAL GANGLIA

• SE of antipsychotics - parkinsons disease , tremor, bradykinesia, cogwheeling, paratonia ( diffuse muscle stiffness), dystonia, akathisia

Question 26

Eye contact

Answer 26

normal - look at each other without staring
Depressed, socially awkward , paranoid, SCZ - avoid eye contact
Manic, aggressive - stare excessively, making the other person feel uncomfortable
Catatonic patients - stare

Question 27

Lead pipe rigidity

Answer 27

Markedly increased muscle tone and resistance to passive movment independent of the direction of movement

Patient is almost as stiff as a board. Muscle tone is SMOOTH and CONSISTENT rather than ratcheting as in cogwheel rigidity

• may indicate brain damage, NMS , acute withdrawal of dopamine agonists in Parkinsons

Question 28

Manipulative

Answer 28

Attitude of behaviour in which one exploits, outsmarts or subtly coerces another person in order to gain advantage, maintain control or get ones own way

• may be subtle or more overt
• Cluster B personality disorders + normal children

Question 29

Mannerisms

Answer 29

A peculiar and repetitive body movement or action that appears bizarre to the observer because it is exaggerated or out of context and does not resemble known types of involuntary movements

• need to know history
• may have a meaning to the patient

Question 30

Motor perserveration

Answer 30

deficient capacity to shift from one motor behaviour to another
- ie. difficulty changing tasks from finger to nose

Question 31

Parkinsonian movements

Answer 31

involuntary movements due to dysfunction of the basal ganglia

TRAP
- resting tremor
cogwheeling
rigidity masked facies, bradykinesia, festinating gait

Seen in EPSES, progressive supranuclear palsy, encephalitis, neurosyphilis

Question 32

Psychomotor retardation

Answer 32

slowing of body movements secondary to psychic dysfunction
accompanied by : hypokinesia or akinesia

seen in: delirium, major depression, drug intoxication or withdrawal, hypothyroidism dementia, schizoaffective disorder

Question 33

Resistance

Answer 33

unconscious or subconscious opposition to attempts by others to help the patient or to bring into the patients awareness information or ideas that are uncomfortable or conflictual

Question 34

Splitting

Answer 34

A psychological defense mechanism in which other persons and things are viewed in extremes , without the ability to consider compromise or to integrate seemingly conflicting information into a whole

Things are “ black or white” , “ good or bad”
The patient idealises or denigrates the same person , or splits groups of others into good guys and bad guys

Question 35

Stereotypy

Answer 35

A repetitive, purposeless movement

• rocking, head banging of autistic children
• more complex than simple tics and unlike automatisms occur without concomitant alteration of consciousness

Question 36

Tics

Answer 36

Abnormal sudden, repetitive, stereotyped jerky movments of eyes, vocal organs, face, extremeties, or trunk