Descriptive Psychopathology: The Signs and Symptoms of ...

174 Section 3: Examination domainslimbs is difficult and cog-wheel can be elicited in the elbows and other joints.Writing deteriorates and becomes small (micrographia) and choppy. Monitoringwriting assesses the effect of antipsychotic medication on the basal ganglia.ParkinsonismBradykinesia with increased muscle tone, features of rigidity, a resting andpostural tremor, a flexed posture, and a shuffling or propulsive gait, define theParkinson syndrome. Postural difficulties occur, and falls are common. Whendrug-induced, it occurs early in treatment and rarely after three months ofexposure. The syndrome is associated with a greasy sheen (sebaceous glandsecretion) when induced by a typical antipsychotic agent.The “on–off” effect seen in many patients with Parkinson’s disease has beenattributed to long-term L-DOPA treatment. Following a gradual decline in thedrug’s effectiveness and rapid dosing adjustments, the on–off phenomenonemerges. The abrupt swings in activity are unrelated to the timing of dosing,occurring many times daily. Transition between states occurs over several minutes,the patient going from “frozen” to a flurry of stereotyped dyskinesia, withflexion–extension leg movements, foot stamping, head turning and hand wringing.Patients sense the change. The “on” state lasts several minutes to hours,with a rapid return to the “off” state that follows on the heels of a return oftremor. Autonomic associated signs are pallor, profuse sweating, palpitations, andextreme lassitude. 83DyskinesiaDyskinesia is involuntary, repetitive, and sometimes distorted movement ofmuscle groups, not due to tremor. Dyskinesias include choreoathetoid (writhing)movements of the fingers, head twisting or overextension, shoulder shrugging,oral–buccal puckering and perioral tremor (the “rabbit” syndrome), lipsmacking, licking, tongue flicking, chewing, blinking, pelvic thrusting, rocking,weight shifting from one foot to the other. Hemiballismus and myoclonus areother examples.Unlike other basal ganglia signs, ballismus is typically associated with a specific,usually vascular, lesion in the subthalamic nucleus or its outflow tracts. Themovement is a sudden, violent and random flinging of limbs. Hemiballismus isunilateral. Facial and throat movements also occur at these moments. In chronicallyill psychotic patients with tardive dyskinesia, the emergence of ballismuscan be mistaken for additional antipsychotic drug toxicity and not a new stroke.Pre-ballismus hyperanalgesia of the affected limb, and the associated agitation,altered arousal, and speech difficulties 84 can be misunderstood as psychogenicand not a newly emerging brain vascular disease process.