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grati cation from certain rhythmic movements, such as rocking, head-banging, etc As discussed in Chap 6, tics and compulsions apparently represent the ful llment of some psychic urge It is the authors impression that a quantitative reduction in spontaneous activity, ie, in the amount of activity per unit of time, is one of the most frequent manifestations of cerebral disease An important aspect of this state, called abulia, is the concomitant reduction in movement, speech, ideation, and emotional reaction (apathy) It is well known that individuals vary greatly in strength of impulse, drive, and energy Some are born low in impulse, with a lifelong tendency to inactivity, a constitutional inadequacy that Kahn called asthenic psychopathy; others are excessively active from early life But with certain cerebral diseases the disinclination to move and act may reach an extreme degree, to a point where a person who is wide awake and perceptive of the environment does not speak or move for weeks on end (akinetic mutism, see page 304) Such patients seem indifferent to what is happening around them and unconcerned about the consequences of their inactivity Abulia and akinetic mutism must be distinguished from two allied states, catatonia and the psychomotor retardation of depression Kahlbaum, who rst used the term catatonia in 1874, described it as a condition in which the patient sits or lies silent and motionless, with a staring countenance, completely without volition and without reaction to sensory impressions Sometimes there is resistance to the examiner s efforts to move the patient (termed negativism by psychiatrists), which is separable from an inability to relax (paratonia or gegenhalten); or there are certain movements or phrases that the patient repeats hour after hour If the limbs are moved passively, they may retain their new position for a prolonged period ( exibilitas cerea or waxy exibility), but usually there is no rigidity except that of voluntary resistance Profound depression or psychopathy are the usual causes of catatonia (see pages 306 and 1311) The psychomotor retardation of depression may be so profound that the patient makes no attempt to help himself in any way and ultimately starves unless fed with a nasogastric tube The whispering speech and demeanor of such depressed patients express their sadness and wish to die In both catatonia and depression, the mind is usually suf ciently alert to record events and later to remember them, in which respect these states differ from stupor But this distinction is not always valid, for we have seen catatonic schizophrenic and retarded depressive patients who could not recall what had happened during the period of catatonia or depression Less easy to understand is a form of lethal catatonia, originally described by Stauder, in which the completely inert patient develops a high fever, collapses, and dies In some respects this state resembles the neuroleptic malignant syndrome, an idiosyncratic consequence of intoxication with neuroleptic drugs (pages 94 and 1025) Pathologic degrees of restlessness and hyperactivity represent the opposite extreme to abulia Akathisia refers to the constant restless movements and inability to sit still; in some patients, this is consequent on the prolonged use of phenothiazines, butyrophenones, and L-dopa, but it is also seen in agitated depressions On page 511 is described yet another form of excessive motor activity, the hyperactivity-inattention syndrome of children, mostly boys In the manic form of manic-depressive disease (and to a lesser extent in hypomania), continuous activity and insomnia are added to the ight of ideas and the euphoric though somewhat irritable mood Following certain cerebral diseases, notably some forms of encephalitis and during recovery from traumatic lesions of the frontal lobes, the patient may remain in a state of constant activity, de-.

Behavioral disturbances of this type are common manifestations of all delirious-confusional states, particularly those of toxic-metabolic origin but also those due to more obvious structural disease of the brain The patient may be completely indifferent to all persons around him or the opposite when any approach may excite anger and aggressive action Family members may be treated with disrespect, regarded with suspicion, or falsely accused of harming the patient, stealing his possessions, or trying to poison him The embarrassment consequent on urinating in public or soiling the bed may be lost and, particularly in men, there may be lewd behavior toward the opposite sex In its most extreme form, usually seen in the later stages of dementing diseases, irascible behavior degenerates to kicking, screaming, biting, spitting, and an aversion to being touched, making it entirely impossible to approach the patient These aspects of disordered mental function are the most alarming to the family and are dif cult to manage in the hospital In contrast, docility and amiable social behavior characterize the Down and Williams syndromes (pages 863 and 888), and social indifference is a major feature of autism (page 889)

Insight, the state of being aware of the nature and degree of one s de cits and their consequences, becomes manifestly impaired or abolished in relation to all types of cerebral disease that cause complex disorders of behavior Lack of insight is a far more complex phenomenon than this operational de nition suggests It might be noted that there are categories of disease, not attributable to obvious structured disease of the brain, in which individuals have a profound lack of insight into their own behaviors; included here are drug addiction, alcoholism, and sociopathy There are also many restricted forms of unawareness of particular neurologic de cits These are the agnosias, discussed in Chap 22 Patients with these diseases rarely seek advice or help for their illness; instead, the family usually brings the patient to the physician And, after the diagnosis has been made, the loss of insight may be re ected in a lack of compliance with planned therapy Thus, diseases that produce the aforementioned abnormalities of mentation also alter or reduce the patient s capacity to make accurate introspections concerning his psychic function