Introduction
1. Disorders of the motor sphere
2. Pathology of speech. Organic and functional speech disorders
Conclusion
Bibliography
Introduction
Speech as a specific mental process develops in close unity with motor skills and requires for its formation the fulfillment of a number of necessary conditions, such as: anatomical preservation and sufficient maturity of those cerebral systems that are involved in speech function; preservation of kinesthetic, auditory and visual perception; a sufficient level of intellectual development, which would provide the need for verbal communication; the normal structure of the peripheral speech apparatus; adequate emotional and speech environment.
The emergence of speech pathology (including cases of a combination of such disorders with movement disorders) is due to the fact that, on the one hand, its formation is caused by the presence of varying degrees of severity of organic lesions of individual cortical and subcortical brain structures involved in ensuring speech functions, on the other hand, by secondary underdevelopment. or delayed "maturation" of the premotor-frontal and parieto-temporal cortical structures, disturbances in the rate and nature of the formation of visual-auditory and auditory-visual-motor nerve connections. In movement disorders, the afferent effect on the brain is distorted, which in turn enhances existing cerebral dysfunctions or causes the appearance of new ones, and leads to asynchronous activity of the cerebral hemispheres.
Based on research into the causes of these disorders, we can talk about the relevance of considering this problem. The topic of the essay is devoted to the consideration of the causes and types of speech pathologies and movement disorders.
1. Disorders of the motor sphere
If we talk about the causes of movement disorders, then it can be noted that most of them arise as a result of a violation of the functional activity of mediators in the basal ganglia, the pathogenesis can be different. The most common causes are degenerative diseases (congenital or idiopathic), possibly triggered by medication, organ failure, CNS infections, or ischemia of the basal ganglia. All movements are carried out through the pyramidal and parapyramidal paths. As for the extrapyramidal system, the main structures of which are the basal nuclei, its function is to correct and refine the movements. This is achieved mainly through influences on the motor zones of the hemispheres through the thalamus. The main manifestations of the defeat of the pyramidal and parapyramidal systems are paralysis and spasticity.
Paralysis can be complete (plegia) or partial (paresis), sometimes it is manifested only by the awkwardness of the hand or foot. Spasticity is characterized by an increase in the tone of the limb like a "folding knife", increased tendon reflexes, clonus, and pathological extensor reflexes (for example, Babinsky's reflex). She, too, can manifest itself only by the awkwardness of movements. Frequent symptoms also include flexor muscle spasms, which occur as a reflex to constant, uninhibited impulses from skin receptors.
Correction of movements is also provided by the cerebellum (The lateral parts of the cerebellum are responsible for coordinating the movements of the limbs, the middle parts are responsible for posture, gait, and trunk movements. Damage to the cerebellum or its connections is manifested by intentional tremor, dysmetria, adiadochokinesis and decreased muscle tone.), Mainly through the influence on the vestibulospinal pathway, as well as (with switching in the nuclei of the thalamus) to the same motor zones of the cortex as the basal nuclei (movement disorders that occur when the basal nuclei are damaged (extrapyramidal disorders), can be divided into hypokinesia (a decrease in the volume and speed of movements; for example, Parkinson's disease or parkinsonism of another origin) and hyperkinesis (excessive involuntary movements; for example, Huntington's disease). Hyperkinesis also includes tics.).
In individual mental illnesses (primarily with catatonic syndrome), conditions can be observed in which the motor sphere gains some autonomy, specific motor acts lose their connection with internal mental processes, and are no longer controlled by the will. In this case, the disorders become similar to neurological symptoms. It should be recognized that the similarity is only external, since, unlike hyperkinesis, paresis, and impaired coordination of movements in neurological diseases, movement disorders in psychiatry are devoid of an organic basis, functional and reversible.
Those suffering from catatonic syndrome cannot psychologically explain the movements they make, do not realize their painful nature until the moment of copying the psychosis. All disorders of the motor sphere can be divided into hyperkinesia (agitation), hypokinesia (stupor) and parakinesia (movement perversion).
Excitement, or hyperkinesia, in mentally ill people is a sign of an exacerbation of the disease. In most cases, the patient's movements reflect the richness of his emotional experiences. He can be controlled by fear of persecution, and then he flees. In manic syndrome, the basis of his motor skills is an indefatigable thirst for activity, and in hallucinatory states, he may look surprised, strive to draw the attention of others to his visions. In all these cases, hyperkinesia acts as a symptom secondary to painful emotional experiences. This type of excitement is called psychomotor.
In the case of catatonic syndrome, movements do not reflect the internal needs and experiences of the subject, therefore, arousal in this syndrome is called purely motor. The severity of hyperkinesia often speaks of the severity of the disease, its severity. However, at times there are severe psychoses with arousal confined to the bed.
Stupor is a state of immobility, an extreme degree of motor inhibition. Stupor can also reflect vivid emotional experiences (depression, asthenic affect of fear). In case of catatonic syndrome, on the contrary, stupor is devoid of internal content, meaningless. The term "substupor" is used to denote conditions accompanied by only partial lethargy. Although stupor implies a lack of motor activity, in most cases it is considered a productive psychopathological symptomatology, since it does not mean that the ability to move is irreversibly lost. Like other productive symptoms, stupor is a temporary condition and can be easily treated with psychotropic drugs.
The catatonic syndrome was originally described by K.L. Kalbaum (1863) as an independent nosological unit, and is now considered as a symptom complex. One of the important features of the catatonic syndrome is the complex, contradictory nature of the symptoms. All motor phenomena are meaningless and not associated with psychological experiences. Tonic muscle tension is characteristic. Catatonic syndrome includes 3 groups of symptoms: hypokinesia, hyperkinesia and parakinesia.
Hypokinesias are represented by the phenomena of stupor and sub-stupor. Attention is drawn to the complex, unnatural, sometimes uncomfortable postures of patients. There is a sharp tonic muscle contraction. Taoky tone allows patients to sometimes hold any posture given by the doctor for some time. This phenomenon is called catalepsy, or waxy flexibility.
Hyperkinesia with catatonic syndrome is expressed in bouts of arousal. Characterized by the commission of meaningless, chaotic, non-targeted movements. Motor and speech patterns are often observed (rocking, bouncing, waving hands, howling, laughing). An example of speech stereotypes is verbigeration, manifested by the rhythmic repetition of monotonous words and meaningless sound combinations.
Parakinesias are manifested by strange, unnatural movements, such as pretentious, mannered facial expressions and pantomime.
With catatonia, a number of echo symptoms have been described: echolalia (repetition of the interlocutor's words), echopraxia (repetition of other people's movements), echo (copying the facial expressions of others). The listed symptoms can occur in the most unexpected combinations.
It is customary to distinguish lucid catatonia, proceeding against the background of clear consciousness, and oneiric catatonia, accompanied by clouding of consciousness and partial amnesia. With the outward similarity of the set of symptoms, these two conditions differ significantly along the course. Oneiric catatonia is an acute psychosis with dynamic development and a favorable outcome. Lucid catatonia, on the other hand, is a sign of remission-free malignant variants of schizophrenia.
Hebephrenic syndrome has significant similarities with catatonia. The predominance of movement disorders with lack of motivation, meaninglessness of actions is also characteristic of hebephrenia. The very name of the syndrome indicates the infantile nature of the behavior of patients.
Speaking about other syndromes accompanied by arousal, it can be noted that psychomotor agitation is one of the frequent components of many psychopathological syndromes.
Manic arousal differs from catatonic arousal in the purposefulness of actions. Mimicry expresses joy, patients strive to communicate, talk a lot and actively. With pronounced arousal, the acceleration of thinking leads to the fact that not everything said by the patient is clear, but his speech is never stereotyped.
For the implementation of the motor act, it is necessary that the impulse from the motor area of the cortex be freely conducted to the muscle. If the cortical-muscular forest is damaged in any part of it (the motor area of the cerebral cortex is the pyramidal pathway, the motor cells of the spinal cord, the anterior root, the peripheral nerve), impulse conduction becomes impossible, and the corresponding musculature can no longer take part in the movement - it turns out to be paralyzed. Thus, paralysis, or plegia, is the lack of movement in a muscle or muscle groups as a result of an interruption in the motor reflex pathway. Incomplete loss of movement (limitation of its volume and strength) is called paresis.
Depending on the prevalence of paralysis, monoplegia is distinguished (one limb is paralyzed), hemiplegia (paralysis of one half of the body), paraplegia (paralysis of both arms or legs), tetraplegia (paralysis of all four limbs). When a peripheral motor neuron and its connections with a muscle (peripheral nerve) are damaged, peripheral paralysis occurs. When the central motor neuron is damaged and its connection with the peripheral neuron, central paralysis develops. The qualitative characteristics of these paralysis are different (Table 1).
Table 1
Clinical characteristics of central and peripheral paralysis
|
Paralysis symptoms |
Central paralysis |
Peripheral paralysis |
|
Muscle tone | ||
|
Reflexes |
Tendon reflexes are increased, abdominal reflexes are decreased or lost |
Tendon and cutaneous reflexes are lost or diminished |
|
Pathological reflexes |
Missing |
|
|
Friendly movements (cinemas) |
Missing |
|
|
Amyotrophy |
Absent |
Expressed |
|
advance action |
Absent |
Peripheral paralysis
Peripheral paralysis is characterized by the following main symptoms: absence of reflexes or their decrease (hyporeflexia, areflexia), decrease or absence of muscle tone (atony or hypotension), muscle atrophy. In addition, changes in electrical excitability, called the rebirth reaction, develop in the paralyzed muscles and affected nerves. The depth of change in electroexcitability makes it possible to judge the severity of the lesion in peripheral paralysis and prognosis. Loss of reflexes and atony are due to a break in the reflex arc; such a break in the arc leads to a loss of muscle tone. For the same reason, the corresponding reflex cannot be evoked. Muscle atrophy, or their sharp weight loss, develops due to the disconnection of the muscle from the neurons of the spinal cord; impulses flow from these neurons along the peripheral nerve to the muscle, stimulating the normal metabolism in the muscle tissue. With peripheral paralysis, fibrillar twitching in the form of rapid contractions of individual muscle fibers or bundles of muscle fibers (fascicular twitching) can be observed in atrophied muscles. They are observed in chronic progressive pathological processes in the cells of peripheral motor neurons.
Damage to a peripheral nerve leads to peripheral paralysis of the muscles innervated by this nerve. At the same time, sensitivity disorders and autonomic disorders are also observed in the same zone, since the peripheral nerve is mixed - motor and sensory fibers pass through it. As a result of the defeat of the anterior roots, peripheral paralysis of the muscles innervated by this root occurs. The defeat of the anterior horns of the spinal cord causes peripheral muscle paralysis in the areas of innervation of this segment.
So, the defeat of the anterior horns of the spinal cord in the area of the cervical thickening (the fifth - eighth cervical segments and the first thoracic) leads to peripheral paralysis of the hand. The defeat of the anterior horns of the spinal cord at the level of the lumbar thickening (all lumbar and first and second sacral segments) causes peripheral paralysis of the leg. If the cervical or lumbar thickening on both sides is affected, then the upper or lower paraplegia develops.
An example of peripheral paralysis of the limbs is the paralysis that occurs with poliomyelitis, an acute infectious disease of the nervous system (see Chapter 7). With poliomyelitis, paralysis of the legs, arms, and respiratory muscles can develop. With damage to the cervical and thoracic segments of the spinal cord, peripheral paralysis of the diaphragm and intercostal muscles is observed, leading to respiratory failure. The defeat of the upper thickening of the spinal cord leads to peripheral paralysis of the arms, and the lower (lumbar thickening) - to paralysis of the legs.
Psychomotor disorders are manifested by sudden rash actions without motivation, as well as complete or partial motor immobility. They can be the result of various mental illnesses, both endogenous (schizophrenia, epilepsy, bipolar disorder (BAD), recurrent depression, etc.), and exogenous (intoxication (delirium), psychotrauma). Also, psychomotor disorders can be observed in some patients with pathology of the neurosis-like and neurotic spectrum (dissociative (conversion), anxiety and depressive disorders, etc.).
Hyperkinesias - states with motor excitement
Conditions associated with inhibition of motor activity
Akinesia - a state of complete immobility - stupor.
- Depressive - suppression of motor activity at the height of depression.
- Manic - at the height of manic excitement, periods of numbness.
- Catatonic - accompanied by parakinesias.
- Psychogenic - occurs as a result of mental trauma ("imaginary death reflex" according to Kretschmer).
Parakinesia
Parakinesias are paradoxical motor reactions. In most sources, the synonym is catatonic disorders. Found only in schizophrenia. This type of violation is characterized by pretentiousness and caricature of movements. Patients make unnatural grimaces, have a specific gait (for example, only on the heels or tangentially to geometric shapes). They arise as a result of a perverse volitional action and have opposite options for the development of symptoms: catatonic stupor, catatonic agitation.
Consider the symptoms characteristic of catatonic states:
Catatonic symptoms also include impulsive actions that are not motivated, short-lived, sudden onset and end. In catatonic states, hallucinations and delusions are possible.
Among parakinesias, there are states in a patient when opposite tendencies are characteristic in his behavior:
- Ambivalence is a mutually exclusive relationship (the patient says: "How I love this kitty," but at the same time hates animals).
- Ambitiousness - mutually exclusive actions (for example, the patient puts on a raincoat and jumps into the river).
conclusions
The presence of one or another type of psychomotor disorder is an important symptom in the diagnosis of mental illness, when the history of the disease, complaints and mental state of the patient in dynamics are taken into account.
Relevance... Psychogenic movement disorders (MDD) are a fairly common problem in neurology; they occur from 2 to 25% of patients seeking neurological care. As a rule, patients bypass many doctors before they are correctly diagnosed, and most often a narrow specialist in the field of movement disorders comes to the correct conclusion. It is advisable to identify the psychogenic disorder as early as possible in order to avoid unnecessary examinations and appointments and to get the best chance of cure.
Pathophysiology... The use of functional neuroimaging methods has shown that in patients with PDD, the amygdala (Amygdala) is in a state of increased functional activity and is more activated to external stimuli. In addition, a more active limbic-motor functional connection was found in these patients, especially between the right Amg and the accessory motor cortex in response to emotional stimuli. Overactive Amg, in all likelihood, involves motor structures in the process of emotional arousal, generating subconscious motor phenomena. By analogy with conversion paralysis, potentially key brain regions functionally involved in the pathological process are the limbic-motor connections and the ventromedial prefrontal cortex. It is no coincidence that the literature describes cases of effective treatment of PDD using transcranial magnetic stimulation ().
Diagnostic criteria for PDD... Until now, the criteria for establishing psychogenic movement disorder have been used by Fahn and Williams (1988). They included sudden onset, inconsistency in manifestations, increased emphasis on painful manifestations, reduction or disappearance of these manifestations during distraction, false weakness or sensory disturbances, pain, exhaustion, excessive fearfulness, flinching from an unexpected action, unnatural, bizarre movements, and accompanying somatization. The diagnostic criteria of Fahn and Williams initially included recognition points for the diagnosis of psychogenic dystonia, later these criteria were extended to other PDDs. These criteria are set out below: [ A] Documented PDD: sustained improvement after psychotherapy, suggestion or placebo, no manifestations of movement disorder when spectators are absent. [ V] Clinically established PDD: inconsistency with classical manifestations of known movement disorders, false neurological symptoms, multiple somatizations, obvious psychiatric disorders, excessive attention to painful manifestations, feigned slowness. [ WITH] Probable PDD: inconsistency in manifestations or inconsistency with the criteria of organic DR, decrease in motor manifestations during distraction of attention, multiple somatizations. [ D] Possible DA: obvious emotional disturbance.
H. Shill, P. Gerber (2006), based on the original criteria of Fahn and Williams, developed and proposed a new version of criteria for the diagnosis of PDD. [ 1 ] A clinically convincing PDD is if: it is cured with psychotherapy; does not appear when there are no observers; the premotor potential is detected on the electroencephalogram (only for myoclonus). [ 2 ] If these features are not typical, the following diagnostic criteria are used: [ 2.1 ] primary criteria - inconsistency in manifestations with organic DR * , excessive pain or fatigue susceptibility to a "pattern" of painful disorder; [ 2.2 ] secondary criteria - multiple somatizations ** (other than pain and fatigue) and / or obvious mental disorder.
* Multiple somatizations are considered as a spectrum of patient complaints, covering three different systems. Severe pain and fatigue were taken into account as diagnostic criteria if they were the dominant complaints, but did not correspond to objective data.
** Manifestations that conflict with organic disease: false weakness and sensory disturbances, inconsistent development in the temporal aspect, a clear dependence of manifestations in response to specialist distractions, sudden onset, the presence of spontaneous remissions, astasia-abasia, selective disability, involvement of tremor in repetitive movements, muscle tension accompanying tremors, atypical response to medication, overreaction to external stimuli.
To establish the levels of certainty of the diagnosis, it is proposed to use the following: [ 1 ] clinically determined PDD: if at least three primary criteria and one secondary have been identified; [ 2 ] clinically plausible: two primary criteria and two secondary; [ 3 ] clinically possible: one primary and two secondary, or two primary and one secondary.
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Psychomotor is called a set of motor acts of a person, which is directly related to mental activity and reflects the peculiarities of the constitution inherent in a given person. The term "psychomotor", in contrast to simple motor reactions, which are associated with the reflex activity of the central nervous system, denote more complex movements that are associated with mental activity.
Impact of mental disorders.
With various kinds of mental illness, disorders of complex motor behavior can occur - the so-called psychomotor movement disorders. Severe focal brain damage (for example, cerebral atherosclerosis) usually leads to paresis or paralysis. Generalized organic processes such as brain atrophy (decrease in the volume of the brain) are accompanied in most cases by lethargy of gestures and facial expressions, slowness and poverty of movements; speech becomes monotonous, gait changes, general stiffness of movements is observed.
Mental disorders also affect psychomotor skills. So, manic-depressive psychosis in the manic phase is characterized by general motor agitation.
Some psychogenic disorders in mental illness lead to dramatically painful changes in psychomotor skills. For example, hysteria is often accompanied by complete or partial paralysis of the limbs, reduced strength of movements, and disordered coordination. A hysterical fit usually makes it possible to observe various expressive and defensive facial movements.
For catatonia (a neuropsychic disorder, which manifests itself in a violation of voluntary movements and muscle spasms), both minor changes in motor skills (weak facial expressions, deliberate pretentiousness of posture, gestures, gait, demeanor) and vivid manifestations of catatonic stupor and catalepsy are characteristic. The latter term denotes numbness or stiffness, accompanied by a loss of the ability to voluntary movements. Catalepsy can be observed, for example, in hysteria.
All movement disorders associated with mental illness can be divided into three types.
Types of movement disorders.
- hypokinesia(disorders that are accompanied by a decrease in motor volume);
- hyperkinesia(disorders that are accompanied by an increase in motor volume);
- dyskinesia(disorders in which involuntary movements are observed as part of the normally smooth and well-controlled movements of the limbs and face).
The category of hypokinesias includes various forms of stupor. Stupor is a mental disorder characterized by the oppression of all mental activity (movement, speech, thinking).
Types of stupor in hypokinesia.
1. Depressive stupor (also called melancholic stupor) manifests itself in immobility, a depressed state of mind, but the ability to respond to external stimuli (circulation) remains;
2. Hallucinatory stupor occurs with hallucinations provoked by poisoning, organic psychosis, schizophrenia; with such a stupor, general immobility is combined with facial movements - reactions to the content of hallucinations;
3. Asthenic stupor manifests itself in indifference to everything and lethargy, in unwillingness to answer simple and understandable questions;
4. Hysterical stupor is typical for people with a hysterical disposition (it is important for them to be in the center of attention, they are overly emotional and demonstrative in the manifestation of feelings), in a state of hysterical stupor, the patient lies motionless for a very long time and does not respond to calls;
5. Psychogenic stupor occurs as a reaction of the body to severe mental trauma; such a stupor is usually accompanied by an increased heart rate, increased sweating, fluctuations in blood pressure and other disorders of the autonomic nervous system;
6. Cataleptic stupor (also called waxy flexibility) is characterized by the ability of patients to stay in the position given to them for a long time.
Mutism (absolute silence) is also referred to as hypokinesia.
Hyperkinesia.
Types of excitement in hyperkinesia.
1. Manic agitation caused by an abnormally elevated mood. In patients with mild forms of the disease, behavior remains focused, although it is accompanied by exaggerated loud and rapid speech, movements remain well coordinated. In severe forms of movement and the patient's speech are not connected in any way, motor behavior becomes illogical.
2. Hysterical excitement, which is most often a reaction to the surrounding reality, this excitement is extremely demonstrative and intensifies if the patient notices attention to himself.
3. Hebephrenic arousal, which is ridiculous, funny, meaningless behavior, accompanied by pretentious facial expressions, is characteristic of schizophrenia.
4. Hallucinatory excitement - the patient's live reaction to the content of his own hallucinations.
The study of psychomotor skills is extremely important for psychiatry and neurology. The patient's movements, postures, gestures, manners are regarded as very significant signs for a correct diagnosis.
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