Les parakinésies. Phénoménologie des mouvements anormaux intrinsèques aux psychoses endogènes

Abstract

Abnormal movements are long known to be intrinsic to some forms of endogenous psychoses. Spontaneous dyskinesia are the ones observed by naïve first episode patients and at-risk subjects. Yet, these are only the rediscovery of more complex phenomena denoted as “parakinesias”, which had been described and documented by extensive kinetographic recordings and long-term observations decades before the introduction of neuroleptics. Unfortunately, they were largely neglected by mainstream psychiatry to the point of privation in the French and English literature. Renewed interest in psychomotor phenomena deems it timely to remind the neuropsychiatric community about that concept. Parakinesias consist of various deformations of psychomotor sequences which, for descriptive purpose, can be separated into parakinesias, i.e. abnormal, dyskinetic-like movements, and parakinetic psychomotricity (PPM). Parakinesias are a form of hyperkinetic movement disorder that is quite specific to endogenous psychoses. Parakinesias can be described as pseudo-reactive and pseudo-expressive motions, i.e. they resemble psychomotor gestures that are not only occurring inappropriately, but that are also somewhat distorted. These deformities do not only affect parakinesias but also the individual style of psychomotor outputs resulting in PPM. Gestures and mimics lose their naturalness and become awkward, disharmonious, stiff, mannered, and bizarre. Parakinetic distortions increase over time, so that parakinesias lose their expressiveness and have a more choreiform appearance. They also become more uniform and stereotyped. PK are prevailing in the upper face and the axial and proximal musculature of the upper body. They are not experienced as self-dystonic or alien by the patients, who are not aware of them, even when their attention is drawn to them. Finally, PK are more frequent and manifest as the level of psychomotor excitement is increased whereas they are attenuated up to disappear under high affinity antipsychotics. In non-naive patients, parakinesias might be mistaken for tardive dyskinesia. When they resemble distorted facial expressions, they fit with the concept of “grimacing” whereas PPM is partly captured by the concept of “mannerism”. The goal of this paper is to enhance recognition of parakinesias beyond grimacing and spontaneous dyskinesias. They deserve to be known by clinicians, especially for their prognostic value. From a general perspective, parakinesias and PPM allow to formulate new hypotheses of psychomotor phenomena that ought to be debated, investigated, and tested.