21st November 2023

Catatonia

In catatonia, there is a disturbance of both mental state and psychomotor functioning. Often, Paper A concentrates on the motor function of catatonic patients, so it is that aspect of the condition which we’ll focus on. For purposes of understanding, the movement types demonstrated will be split into two categories: abnormal psychomotor activity and decreased psychomotor activity (modified from the ICD-11). The ICD-11 also has a third category, Increased Psychomotor Activity, which includes impulsivity and agitation.

Abnormal psychomotor activity

Echophenomena

This is an encompassing term for two conditions where the patient imitates the clinician (Ford, 1989)

• Echolalia  – The patient repeats the speech.
• Echopraxia  – The patient copies movements.

Grimacing

Spontaneous contraction of the facial muscles into odd facial expressions, which are not congruent with the situation. A grimace is often maintained for a prolonged period of time.

Schnauzkrampf is a variant of grimacing whereby the lips are pushed out and look like a snout (Casey and Kelly, 2019).

Mannerisms

Mannerisms are goal-oriented movements made by the patient that are often oddly exaggerated (Kaufmann et al., 2018). Movements seen include saluting.

Stereotypy

A patient makes repetitive movements; however, unlike mannerisms, they are not goal-oriented and are suppressible. These types of movements are also seen in autism spectrum disorder and intellectual disability.

Examples of movements seen are flapping of the hands and rocking of the body.

Posturing

This is where a patient spontaneously takes up a position against gravity and then holds this for a prolonged period of time (American Psychological Association, 2023). This is known as catalepsy when it is the examiner who places the patient in the held position.

Rigidity

There is increased muscular tone, leading to the resistance of movements.

Waxy flexibility

This is also known as cerea flexibilitas, and it is where the patient maintains any position in which their limbs are placed. There may be a little resistance to the movement by the patient.

Please note that the literature gives several different descriptions of catalepsy and waxy flexibility. I’ve adapted the ICD-11 definitions here for clarity.

Decreased psychomotor activity

Gegenhalten

This is also known as negativism. The patient refuses to obey commands or resists the movements of body parts, often using a force which is equal to that applied by the examiner (Wijemanne and Jankovic 2015). Negativism can lead to aversion, which is where the patient turns their body away from the clinician during an interaction.

Autonomic obedience

This is where a patient complies with all requests/commands with an exaggerated response (Wijemanne and Jankovic, 2015). They comply with these requests even if they would normally be regarded as dangerous. It is the opposite of negativism. The most famous (and memorable) demonstration of autonomic obedience was in the research done by Kraepelin (Casey and Kelly 2019), whereby he stuck a pin in the tongue of his patient every time his tongue was stuck out. The patient continued to stick out his tongue as requested despite the pain being inflicted on him.

Mitmachen and mitgehen (Rajagopal, 2007) are types of automatic obedience:

• Mitamachen  – The patient can be put into any position by the examiner and does not resist this movement even if instructed to.
• Mitgehen  – As with Mitmachen, the patient’s body can be placed in any position; however, this is a more extreme version whereby the limbs move much further than the force applied to them. In fact, it takes very little force to move a limb. This is also known as the ‘Anglepoise lamp’ sign (a phrase that crops up in exam questions).

Ambitendency

Here, the patient appears to be in conflict around moving their body. They will, therefore, make partially complete stilted movements that are goal directed (Casey and Kelly, 2019).

Stupor

A patient is alert. However, there is minimal interaction with the environment – Be that with no motor or verbal interaction (Wijemanne and Jankovic, 2015). This is seen in depressive states.