Descriptive Psychopathology: The Signs and Symptoms of ...

158 Section 3: Examination domainsit as a voluntary or habitual act such as brushing hair from the forehead. Overflow isalso elicited by having the patient walk. Pronounced extension of the fingers (forkhand) or other unnecessary hand postures may be seen. In its severest form, chorea isseen as writhing, dancing movements.Fine motor problemsRapid finger tapping requires sustained attention and fine motor control. Thepatient is asked to tap his index finger as rapidly as possible for 20s, palm flat ona table or thigh. When motor strength is adequate and arthritis is minimal, 40 ormore taps with the preferred hand is an expected performance in persons under70 years of age. Healthy older persons achieve 30 or more taps in 20s. As onehand performs, the other, also palm down on a thigh or table, is watched foroverflow. Drumming one’s fingers in sequence from little to index finger combinesfinger tapping with motor sequencing. Patients with chronic behavioralconditions commonly have problems with finger tapping and motor sequencing.Poor performance is a sign of basal ganglia disease, hypothyroidism, and depressiveillness. 22Motor sequencing difficultyThe completion of a task requires a sequence of movements. Skilled sequences(e.g. suturing) are over-learned. The ability to create novel motor sequences isnecessary in learning new tasks, and is tested by asking the patient to perform asimple continuous movement. Motor strength must be adequate and the patientmust understand the task. The patient is instructed to use one palm, a thigh ortable top as the surface and then to rapidly place the other hand in a fist on thatsurface, raise it, come back down with the side of the opened hand, raise it, andcome back down with the palm on the surface. The sequence of fist, hand edge,palm is repeated five times with each hand. Abnormal performance includesslow, awkward and hesitant movement, out of sequence movements, repeatinga movement (perseveration), and combining movements (e.g. hitting the surfacewith the hand edge as the fingers flex into a weak fist). Patients with depressiveillness will have problems with sequencing that resolve with episode remission.Sequencing problems persist in patients with chronic psychotic disorders anddisease in the frontal lobes.Catatonia 23Catatonia is a syndrome of motor dysregulation. Variations of catatonia rangefrom patients with a few features to those whose catatonia dominates the clinicalpicture. Many conditions elicit catatonia. The most common sources are mood