Second edition

04.qxd 3/10/08 9:33 AM Page 140
140 Other signs and symptoms
Clinical features
Examples may help fix this sign in the reader’s mind. When
attending his brother’s funeral, one patient, while feeling
nothing but grief and sadness, was noted to have a strange
grin on his face; another, although reporting pleasure at
receiving a gift, was noted to grimace as if in pain.
Etiology
By far the most common condition in which inappropriate
affect is seen is schizophrenia (John et al. 2003) and the
closely allied schizotypal personality disorder (Fossati et al.
2001). Such affect has also been noted during intoxication
with hallucinogens, such as ketamine and dimethyltryptamine
(Gouzoulis-Mayfrank et al. 2005), and in the very
rare velocardiofacial syndrome (Sachdev 2002).
Differential diagnosis
Inappropriate affect, as defined here, must be distinguished
from the far more common ‘socially’ inappropriate
affect. For example, smiling at a funeral, although
certainly socially inappropriate would not be considered
pathologic if the person smiling felt a sense of triumph at
the death of a hated rival, for here there is no mismatch
between what is felt and what is displayed.
‘Nervous laughter’, for example when someone laughs
to cover up a feeling of sadness, although indeed representing
a mismatch is distinguished by the fact that the covering
laughter can be easily dispelled with a few sympathetic
questions, after which the laughter is replaced by an appropriate
look of sadness.
Aprosodia of the sensory type, as discussed in Section
2.7, is quite similar to inappropriate affect in that in both
these signs there is an incongruence, or mismatch, between
what the patient feels and the tone of voice with which that
feeling is expressed. The difference is that in sensory
aprosodia, patients also have difficulty in comprehending
what others feel by listening to the tone of voice with which
others speak, whereas in inappropriate affect patients
retain this ability.
Treatment
Treatment is directed at the underlying condition.
4.27 MANNERISMS
Manneristic transformation of gestures or speech, or of
activities such as walking or eating, although most common
in schizophrenia, may occur in other disorders. The resulting
mannerisms often strike others as peculiar or bizarre.
Description
Kraepelin (1907) noted that patients with mannerisms
may ‘. . . walk with a peculiar gait, drag one foot, go in
straight lines or in circles, hold their spoons at the very end,
eat in a definite rhythm, and shake hands with extended
fingers’. He felt that mannerisms were ‘. . . especially common
in speech (with) . . . grunts, lisping, peculiar words,
phrases and inflection’.
Bleuler (1924) commented further regarding the manneristic
transformation that gestures may undergo, noting
that ‘. . . every conceivable stilted gesture occurs. Shaking
hands is done very stiffly with the hand turned or only the
little finger is presented; the hand may be shot forward
quickly and withdrawn just as rapidly’.
Etiology
Although mannerisms are most commonly seen in schizophrenia
they may also occur in mental retardation (Leudar
et al. 1984), autism (Sears et al. 1999), ketamine intoxication
(Krystal et al 2005), and in cases of dementia occurring
in the elderly (Rabinowitz et al. 2004).
Differential diagnosis
Stereotypies are distinguished by their monotonous
repetitiveness.
In patients treated chronically with antipsychotics,
mannerisms must be distinguished from tardive dyskinesia
(Granacher 1981). One clue to the differential lies in the
presence or absence of a motivation for the behavior in
question: mannerisms represent intentional behaviors that
have undergone a bizarre transformation; the abnormal
movements of tardive dyskinesias, in contrast, are involuntary
and occur in the absence of any motivation.
Treatment
Treatment is directed at the underlying etiology.
4.28 STEREOTYPIES
Stereotypies represent a kind of perseverative motor activity
in which behaviors are repeated again and again in a purposeless,
monotonous, and thoroughly stereotyped fashion:
they may range from such simple behaviors as hand flapping
to complex activities such as repeatedly taking apart
and then putting back together a small machine. Importantly,
although some of these stereotypies appear, on the surface,
to be purposeful, patients are unable to adequately explain
why they repeatedly engage in the behavior.