Descriptive Psychopathology: The Signs and Symptoms of ...

164 Section 3: Examination domainsThe patient is often unaware of these behaviors. Psychotic patients with stereotypicbehaviors can be mistaken as having obsessive–compulsive disorder. 41Stereotypic movement disorder has been given a separate category in presentclassification when its onset is in childhood. 42 Head shaking and banging,rocking, self-biting, picking at skin or body orifices, and hitting oneself aredescribed, often in association with mental retardation. These stereotypes, however,also occur in adults without mental retardation. When the patient exhibitsthe tendency to make automatic movements seemingly in response to an externalstimulus, the term is proskinesis. 43Automatic obedienceAutomatic obedience is the inability to resist tactile stimulation, despite instructionsto the contrary. The patient is encouraged to hold the arm of a chair or thebed sheets tightly and to not let the examiner open the grasp and move the hand.Despite this continued encouragement, the patient submits to the examiner’sgentle manipulations.Mitmachen is observed when there is only mild initial resistance to the examiner’sefforts. When the examiner releases the patient’s arm it returns to its resting position.Mitgehen is observed when the patient responds to the slightest touch, even tofollowing the examiner about the room (magnet reaction). In another example, thepatient is told to keep his arm “limp” as if asleep and let the examiner do “all thework”. The patient, however, cannot resist the stimulus of the examiner’s manipulationsor the light stroking of the hand, and the patient’s arm follows the stimulus andcan be postured by this technique. When asked, “What is your arm doing up there?”the patient may look at it in bewilderment, saying, “I don’t know.”Forced grasp may be elicited by lightly stroking the patient’s finger tips, despiterepeated instructions not to grasp the examiner’s hands. The rigid patient maybe lifted from his bed by the finger tips. At other times, the examiner moving thepatient’s hand in a repeated simple motion (e.g. rotating the wrist while holdingthe fingers) elicits a perseveration of the movement that continues after theexaminer releases the patient’s hand.AmbitendencyCatatonic patients cannot make choices. Competing stimuli requiring opposingactions elicit indecisive movements, hesitancy, or the appearance of being stuckbetween movements. The examiner offers the patient his hand as if to shakehands, while stating “Don’t shake my hand. I don’t want you to shake it.”Ambitendency is present when the patient extends his hand as if to shake hands,moves his hand back-and-forth unable to complete the movement, or lightlytouches the examiner’s hand.