and John Dennison2
(1)
Department of Psychological Medicine, University of Otago School of Medicine, Wellington, New Zealand
(2)
Department of Anatomy, Otago Medical School, Dunedin, New Zealand
Clinical presentations of a puerperally-induced and a menstrually-induced hyperkinetic motility psychosis
Pseudospontaneous movements
Idiosyncrasy of the movement
Absence of compulsive speech in this
Psychomotor compulsive speech
Description of a case of jacktatoid compulsive movement
Verbigeration in compulsive speech
Choreatic compulsive movement
Impulsive actions
Disarrayed restless movement
Hypermetamorphotic compulsive movement
Periodic recurrent course of the illness
Prognosis and treatment
Lecture
Gentlemen!
The patient who you see looks feeble, pale, and exhausted. In fact, for 4 weeks she has been in a severe state of arousal, in which she has produced an excess of movements, which probably explains why all her energy has been quite used up. To our great surprise, a turn-around occurred from yesterday, after she had been in constant motion the day before, mostly with histrionic-melodramatic expressive movements, and had been singing virtually without ever stopping. The way she carried out her singing was certainly surprising: It was accompanied by a fine tremor of her lower lip and the whole of her lower jaw, a movement akin to that of chattering teeth, but without the teeth ever occluding. Her voice thus attained a regular, tremulous character, reminiscent of many barrel organ performances, the more so as she sung only the notes, without accompanying words—evidently a wholly invented, sustained hymn, almost always at very high pitch—with steady, quiet ‘conducting’ [Ed] movements.
This singing, which, along with the patient’s troubled, perplexed and unhappy facial expression, gave her a ‘constrained’ [Ed] look, hindered her eating food; and it ceased only in the evening, when, after of an injection of hyoscine and morphine, sleep ensued for several hours.
Firstly, convince yourselves of the extreme exhaustion and frailty of this patient. When she is raised to her feet, she sways and needs support; seated on a chair, she occasionally lets her head fall back, apparently in extreme fatigue; and she appears distracted when enquiries are made, or begins to answer, but soon loses the thought and stares into space. Evidently, she is able to follow only with effort, and I could not ask more of her, because she really is very much in need of rest and protection. Yet her perverse facial expression is remarkable to us: Firstly, she opens her eyes so wide that the whites can be seen above the cornea; then she wrinkles her forehead as if in anger, and again protrudes her lower lip and lower jaw. Further, at times, we see marked impediments in her speech: she forces out a single word like a stutterer, labouring a long time over initial consonants; or occasionally, she utters gurgling, inarticulate sounds; and she is unable to show her tongue when requested, but only opens her mouth in an awkward manner. Words are often toneless, and therefore unintelligible. Yet at other times she speaks with no trouble, and in this way tells us how her illness started. She is able to give her name correctly, her age, and the date of a previous confinement; she also expresses her feeling of being ill, that she feels dizzy, and cannot breathe properly. She also admits that the clinical examination took its toll on her. Now and then she turns her head and listens, evidently attracted by phonemes. She often turns to the female attendant beside her, as if for help, and it can be seen how hard it is for her to stay attentive. Yet familiar things, like the Lord’s Prayer, seem to give her no trouble; she repeats it in a devout tone, with folded hands. She then voluntarily repeats Luther’s exposition on one of the Ten Commandments, and begins to sing a chorale, with faultless words and melody. I then raise her right arm to a horizontal position; she permits this without resisting, and holds the position for a short time, before letting her arm sink. Bending her head forwards produces pain, and is met with mild resistance. When she stands to leave the auditorium, she spreads her arms sideways, palms supine, and makes a theatrical gesture, but then follows the attendant in the normal way.
Gentlemen! As you have seen the patient’s mental state was not normal. First of all, apathy equating to exhaustion seemed to prevail, then moods of euphoria or irritation appeared, all within moderate limits, and always combined with expressions of helplessness and disarray. She was not visibly, or not adequately orientated to her surroundings and situation, and made the strangest statements about her own body: Last night she had a ‘hump’ [Ed], which has gone away again, and her ‘eyes have been slashed’ [Ed]. Any explanations we could obtain about the cause of her movements were quite incomplete; a few isolated statements seemed to show that she had been ‘compelled’ [Ed] to sing and dance.
Gentlemen! As I soon concluded, our patient has suffered a pronounced hyperkinetic motility psychosis over 4 weeks, and we see the subsequent state of exhaustion clearly showing signs of this illness, which are largely motor in character. Her facial expression conveys no psychological motivation; and the occasional protrusion of the lower jaw and lips, the peculiar impediment of speech, the fluctuating inability to protrude her tongue, the pseudoflexibility, unmotivated histrionic gestures, and equally motiveless singing are all distinct remnants of the preceding motility psychosis, to be interpreted partly as parakinetic, partly as akinetic symptoms.
With regard to the aetiology of our case, we know only that the illness developed acutely over the course of a few days, after the patient, a 27-year-old potter’s wife, married for 9 months, had experienced her first- and normal-delivery at the women’s clinic, and had remained psychically normal for 10 days. She had breastfed another child besides her own, and was thus somewhat debilitated. At home she was greatly worried about her child, listening to every breath, expressed fear that he might die; and on the second night after that, she began to sing, to dance around the room and to talk about angels, who she could hear singing. The next day she mistook her husband for a physician she knew. The hyperkinetic motility psychosis has developed, as it often does at the end of the puerperium, which, as we learn, is perfectly normal; and the patient is therefore an example of the falsely named ‘puerperal mania’ [Ed], which in reality covers all manner of acute psychoses, pure mania being the least common.
Gentlemen! Chance has favoured us, in that I can present another patient, in whom you will see the florid stage of a hyperkinetic motility psychosis. You witness the patient entering, dancing a waltz step and singing a waltz melody. She then taps the crown of her head with the flat of her hand and says ‘Holy water’, bows, and repeats the word and the same gesture five more times. She correctly interprets the gesture I make with my hand, inviting her to take a seat, and suddenly sits down in the chair. However, she soon stands up again, bends forward, and throws her head forward so that her loosened hair falls over her face. She repeats this rhythmically about 20 times. Then she walks round, her body bending and swaying, busily gesticulating and talking incessantly, with regularly accentuated steps, reminiscent of the enforced exaggeration in the expressive movements of a minuet. The rhythm of such dancing, hopping, and jumping whole-body movements is remarkably exact, when pushed to the limit and, in their execution may indicate great expenditure of energy. They are accompanied by movements of the arms, expressive and correspondingly energetic. Her face also displays an exaggerated countenance; she rolls her eyes, makes an angry face, and then a haughtily repellant, or comical one. She makes threatening movements, attempting to strike—but not in earnest—these being deflected immediately by herself. At the same time she makes several interconnected assertions, at one point: ‘They (or you? not decided) must be chopped up at the stake’. On the whole, her mental state, like her movements, seems to be very unstable, sometimes extremely happy, then haughty or irritable. In general she cannot remain in one place, or can do so only for a moment; at one point, when asked “Why do you dance? Are you happy?” she promptly answers in the affirmative. Then, when asked ‘Do you know who these gentlemen are?’ she begins to sing, ‘So might Heaven forgive you’.
The connection between her spontaneous, almost-continuous speech movements and her other movements is most extraordinary. It is shown in that her voice is often raised, matching the rhythm of her general movements; and, this happens to a greatly exaggerated degree, as are her movements. Thus, much of what she says is incomprehensible, or she gives voice to no more than fragmentary sentences or isolated words or syllables. Furthermore, the content of these isolated fragments of speech is often connected conspicuously with the movements. Thus, she adopts a military bearing, makes the movement of stroking a moustache with her right hand, and says in a gutteral tone ‘Lieutenant of the guard’. On another occasion she raises her arm, bent at a right angle, opposes the tips of thumb and index finger with the gesture of the gourmet, and says ‘Roast pork’; or she extends her arms and hands and says ‘I still have ten healthy fingers’; or, while she has her arms outstretched and sways her torso: ‘How can the tailoress balance?’ Evidently these movements completely divert her attention, so that only momentarily can it become focused. Moreover, you have seen that incidental sensory impressions divert her, and lead to movements, although mainly she ignores my questions and requests. Nonetheless, when she has been enticed to sit down, limiting herself, in silence, to theatrical hand movements, and I say to her ‘she can go now’ [Ed], she at once comprehends this correctly, and stands up.
Gentlemen! This patient, a 36-year-old unmarried tailoress, also looks pale, emaciated and worn out, quite a natural consequence of the effort she has expended in almost-continual, unchosen movements. She has been in this same state for 5 weeks, varying now and then only in intensity. Sleep can be induced only by hypnotics, of which hyoscine seems especially effective; food intake is inadequate, and is disrupted by her motor restlessness.
With regard to this patient’s clinical history we have learned the following. Psychoses or severe neuroses have not occurred before in her family; her father died of consumption at age 52. She had been a poor student at school, but was industrious, very honest, and had led an orderly life. She carried on a tailoring business with her sister, and has probably overworked; and over recent years she also suffered from menstruatio nimia [W]. Eight years ago, she had been depressed for 3 months, probably with melancholia; at any rate, she conveyed feelings of unhappiness, spoke with self-reproach, and at the time her relatives had noticed peculiar ‘knotting’ [W] movements of her hands. Afterwards she had been healthy, except at the times of her menses, when she always became markedly irritable and sensitive. Eight weeks prior to admission she had a 2-day premenstrual attack of ‘frenzy’ [Ed], in which she talked and sang constantly, always in motion, throwing furniture about, and had terrifying visual and auditory hallucinations, with verbigeration, occasionally mistaking people and her surroundings. From the family’s description, she had very prominent hypermetamorphosis at this time. With onset of menstruation she quickly became quiet, and slept spontaneously. Four weeks later, menstruation passed without disturbance. Two days before the next menstruation, which was exactly 4 weeks later, admission to the clinic became necessary because of a fresh attack of frenzy, after having spent 2 days at home in this state. This time, appearance of her period had no influence on the illness. To-day, at this demonstration, she should have menstruated again, for it is 5 days over the 4 weeks since her last period, but this time, menstruation seems delayed or not to be happening at all.
Gentlemen! These data are of special value, because they show us a definite, though rather imprecise, influence of menstruation upon the origin and decline of psychoses, and—I must note here—that this is not an isolated experience, but recurs so often in hyperkinetic motility psychoses that we need to recognize it as, by far, the most common type of menstrual psychosis. In particular, hyperkinetic motility psychosis is more often of menstrual than of puerperal origin. I return to these aetiological circumstances later.
Gentlemen! Strange and outlandish as are the movements that you have seen in our patient, they might leave you suspecting that they are—in part at least—voluntary productions of a hysterical-histrionic personality. Admittedly, there are no hysterical antecedents, and the fact that being left alone has no influence also contradicts this, for it is not clear why a hysteric should continue such performances when there are no witnesses. Finally, there are patients’ own statements made after they have recovered—or when they become calm just for a while—that these movements are independent of their volition, the result of some incomprehensible kind of coercion interpreted in various ways. However, you will reasonably ask for positive signs, to allow such pseudospontaneous movements [W] to be differentiated from deliberate productions. There actually are such signs, as you have seen in our patients. A certain uniformity and monotony of these movements, their tendency to recur with the same pattern of movement, perhaps increasing to rhythmical repetition, will be especially striking to you. It is manifest also in verbal performance, and has repeatedly led to verbigeration in our patient. Second, you will not have missed the exaggerated, violent, and to some extent affected character of these movements, along with the unusual muscular effort with which they are connected, giving some of the movements a grotesquely graceful appearance. In our patients this is also noticeable in their speech movements; and this is not always limited to pseudospontaneous movements, being occasionally incorporated into expressive ones, like laughing, crying, and singing. You will probably remember the patient (p. 75) who apologized for her song, irreproachable in itself, that she had to sing, a production in itself perfectly proper; but she had to sing it, even though she did not want to. Finally the evident aimlessness—and absurdity—in the form of her movements, must be emphasized, for instance, when the patient repeatedly placed the flat of her hand on the crown of her head, or spread her fingers, or rhythmically bent her body forward, or balanced on one leg, etc. This aimlessness differentiates pseudospontaneous movements from the so-called ‘occupational deliria’ [Ed], usually connected with compound hallucinations, repetitive to the point of perfection, and also from a psychosensory component of conditioned reactive movements (as in alcoholic delirium) driven especially by cutaneous hallucinations. However, when the movements resemble gymnastic exercises, as we often saw in the past semester, you find them here, in our clinical demonstration, totally out of place and evidently aimless.
Gentlemen! Closer analysis of the pseudospontaneous movements brings anecdotal evidence to our notice, namely that the movements are not psychologically motivated, but are a consequence of disordered identification between Z and m, that is, on a psychomotor pathway. Items of clinical evidence, which are only occasionally prominent in our case, lead to the same conclusion, in so far as the patient spoke a lot—although in many cases of hyperkinetic motility psychoses, this will confirm the diagnosis almost at first sight. The evidence is that the motor impulse of hyperkinetic motility psychosis is accompanied not by corresponding loquacity, but often by the opposite symptom in the speech domain, namely mutism. A striking contrast always exists, a lack of proportionality between the mild degree of loquacity and the severely affected motor impulse. As you can see, this is the direct opposite of mania, where loquacity predominates and the motor impulse retreats in proportion, or is manifest more as a ‘desire’ [Ed] for activity. But if pronounced loquacity exists, which is commonly the case, the changed form of speech shows that it originates from a psychomotor disorder of identification. Its undifferentiated form leads to verbigeration, or at least to conspicuous repetition of the same words or common phrases; excessive expenditure of effort leads to unmotivated crying or howling; the aimlessness in gratifying the vocal motor impulse leads to senseless stringing together of words, and of words or syllables not even related by sound. In general the signs of psychomotor loquacity—unlike those of an intrapsychic disorder—are monotony and incoherence rather than flight of ideas. A further sign referring to content is provided by the hypermetamorphosis which is hardly ever absent in hyperkinetic motility psychosis. The following reproduction of the spontaneous utterances of a patient may illustrate what has been said:
Scullion or bubble, then it begins to bubble or to burn, or with others, ah, Jesus, says my Mutho, always from the beginning, if she was so small, ah so, ah, Anna, a, n, a, in the height, or so much drops from above, ah, Jesus, I findest thou, ah, Jesus and hence because she scullion, getel or gattel or Philadelphia or America or in Tyrol or the or doubles, ah, pocket pistol with and without a bang, since the matter is so, oh, Jesus, Jesus, it goes once, 2, 4 therefore so much even as one once goes to me so, so straight out, then 2, 3, ah, Jesus, ah indeed, that is very fine, that is called counting, the first, the first little song, oh Jesus, consequently one says work or destroying angel [strangling movements!][to the attendant:] I might take away the cushions, for so many things, ah, Jesus, little star, her little child, come oh, come, oh not yet, just the same. Stop, what is it, what is it that comes from my home, ah, Jesus, ah, ah, ah, or from my school friend from the beginning either from Hanke, Anke, kekeke…Related posts:
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