Psychomotor effect in athetoid patients

Oral

Medicine _..-.-- .._...

PSYCHOMOTOR EFFECT IN ATHETOID _-__.. ..--. ..

PATIENTS

Report of Two Cases

I ITHIN recent years cet*el)ral l):tlsy has ctncrgetl as :I l~t~~l~1ct1tcletttatttlittg increased attention by the tnetlicnl ~)t*ofessiott. 'l'he condition was originally thought. to result front birth t rauttta. (!arr’ettt statistics, however, though ftxgtnent.ary, indicate a. constant, t*rgulnt* tlistt*ihutiott, wit.h seven cases ot’ cerebral palsy occurring in c~vct*y ,100,OOO births.‘. 2 Thus, failure of brain development in utero, Rh reactions. atttl a nutnl:et* 01’ other factttws should 1:~ considered of etiol0gir.n.l sigiiific:itic~e. I’tbSttlntill accidents 01’ itrfections p;dsq'. affecting brain development lllily also cause cerehrsl (‘erebral palsy is a gettct*ic term which includes sc~vet*al subdivisions, each a type of neurotnuscu1a.r ittcoo~tlitiatioit. Spastic ~a~ra.Zysis occurs with lcsiotis ol the cortical motor areas 0-f the Keoiproc?al ttltlvetti(~tits of brain? resulting in a hyperactive strctcalt r&x attt.ngottist muscle groups arc’ prevented 01’ restrktctl. (lonstattt, irivolutttar~ reflex Athetosis implies ittrolittitar~ittovettient. muscle contractions result from lesions ol the extrapyramidal t.racts. .4taxia, in which balance is disturbed ; G!/i&y, rhatacterixell by muscular st.iffttess, and tremor are other s~tnptotns l’rcyuent in cerebral palsy. :ltt most inst.ances these l)hettotttetta t~cur itt c~otttl)ittat,iott. ‘l’htl nthetoitl and spastic paralysis groups togrth(~t* cottiprise about three-I’onrths of thv reported cases of cerelxtl pnkYr.

W

II. Personality Maladjustment of Physically Handicapped There exist in the litct*;tturt? two scl~ot~l~ of thought cottccrttittg the route by which personality tttitlatl,jttst.tttt~ttt occurs it1 the l~ltysit~;tlly ltsttdicapped. One group of authors feels that thtl tnort~ ~~rrsewt~ 01’ ;1 physical handicap is, in itself, sufficirttl to ~~rotlut~c personality disorder. Others tnaintain that poor family emotional environment is the prime factor in causing maladjustment. Phelps says, “. . . the presence of t.he cerrlwal palsy itself is not the basic 1factor] for the type of response to sit.uat.iotts, hut. rather [it is] ihc specifici t.ype of motor disturbance which is the detertninittg .factnt*. ” Responses arc considered psychologic varia.tions ot’ first,. the early acquisition ol’ t.he hantliAthetoid cap, and second, the result of t,he various t,ypes of t.he involremenl. paGent.s, for esample, Phelps foutttl t,o show almormn.1 displays of both anger 1122

and affection alternately, these iiswings” being so constant. as to constitute part of the athctoid picture.4 Wile.L believes that. crippling af’fscts intelligence, stability, and social equilibrium through interference with I~OYII~;~ (I(~vclopment, afleeting the ’ ‘ ornotional. evolution. ” The appearance of an inferiority complex in childhood as the result of crippling has l)ecn studied in conditions other t.han cc!rcbral palsy.” lmd’~ feels that the parent relationship is the decisive factor when personality maladjust.ment occurs in children with cerebral palsy. The child’s atljustmcnt depends on t.he emotional sbahi1it.y rai.her than t.he intellectual or mxrly normal mental attainment of the parents. Children of nom:~l development presented the major adjustment problems, “. . . some of t.his group [being] in practical control of the &nation through domination over slaves who ea.nnot cope with the demands of a dotheir parents ,-willing mestic tyrant who is physically helpless. ” I
1124

,WI Sb’\’ 1 I1. 1IOROW11’7 1

Case l.-The patient was a whit.e III;II~, il~,vCC’l 10: displayilig I~lod(~l*;Itcl~ severe’ athctosis wit.h involvemr~ut 01’ the c~strcmitie,s? Ileck, and f’aeia I III~s~Iw. Th~c was a brother, aged 15. of IIOIYIMI tllent;Il and physical. (lcvctlol~lllc~~lt. I’rp~zGms Lhtd ~Zistm~!~.-.-l)i;lRnostici ~~rwetlure rluring orthotlontic (*onsulfafion had includetl iIlt~*:Iotxl alId (~st~a(>~*ill rorllt gelIogCl*;trns, ;Illtl imprclssions for study casts. Thetxh had been IIO rc!storativc tle1lt;l.l tl*(!iltltI(hnt. At: his first, visit the lmtient mmed to IW l)right., gregarious, ;I IIt1 inq&it ire. He answered questions iu good hImor, professing to tAnjoy school and group activities. Thr mother al)l)(~ilretl to be an intelligellt, ill(lust.l*ious WOIN~.II who worked a~ iI elr1.k ill ;I “SUI)C~~~lla1*k~~~”i,i ortler to Ilc~lster tticl f;I.lnily finances. The father’s wol*k, utIfort,IuI;lt.ely. nmtlc it impossihl(~ to obtain an iIIt.erview with him. ‘I’hc mother tlescrihetl the Family IiI’c iis “110rn1;I.l” a ntl “cheerful.” She disclosc(l t.he Cact that the ;Ith(ltoitl I~oy hatI I)t1cll POIIsignctl t.0 illl inst.itution I’or tIltI feeblr-miniletl ilt ttlt’ ;Igc of 7. IWing ill that time unable to speak, read. or write. That parents had rcl’usctl to accq~ what t hc> felt. to 1~ an unjustified ;ll)l)I’aisal of the t)oy’s abilities. Atlr(luilt:’ tl*ilinillg ant1 t.herapy had been pro\:itlcltl despite sevc~rr st railI oII t.he I’amily r~c*onol~ly. with th(l result t.ha.t t.he I)oy h.atl r~;I~hetl, wit.hill a ~hree-yc~ar l)t~riotl. iI stat,r of self-sufficiency which coultl 1~ consitleretl n(~rnIill l’or his age. The pstient expressed il willingness to c!ool)clratth iI1 ihe cco~ltetnpla.t~(l treat,nIent and at first sat quietly in t.hc dental (*hair. Howcvrr. when tht? (leIIt;ll hadpiece wils I)rought towilt his nlonth, thr IN)~ l)ttc:lltlt* SO hyl)rl*kinetic t.hat t.he handpieccl was removctl in orcler to l)rclvent possible in,jury. These ja&t.at.ions ceased grsduil I ly. The ljatient. t.htall 1~ga11 to (dI*y. itlthough up to this tirnc IIO real attetlIl)t at rendering frt!itfljl(allt hat1 been miItl(l. N’hcIl yuiet. he revealed iIn inlensc I’WI ol’ aIlyfhi1lg that woultl “hurl.” him. It. was possiblr to allay this fra 1’ at sut)sequent visits through the use OC lo(!i\ I u.nest,hesia. The lmy nev(‘t* ;lgxin espt~ricncetl thth clscessivc tlyskin(Ga which ha.d 0~nrr4 at, thr time trt*;ttnleIIt was originally :Ittellll)tetl. S(~\-~~~*al c;IrioIls teet,h were rest.oretl ovel* iI l)rriod c~fmonths. Case 2.-The patient was a l.O-yea~~-~~ltlwl1it.e male with moderately severe at.het.osis and involvement of the extremities, neck, iIn<1 facial mus(*l~ There were tI0 siblings. Previous dental espcriencrs hat1 I)ern traumatic. Several t1entist.s ha(l The pawtlts t’elt that this was due to at.tempted trent.rnent unsuccessfully. the fact t.hat t.hese dentists hat1 “hat1 no l)atience’) wit.h their son l)eca.use OI his physical handicap. The pabient appearctl slq)rehensive a1I(l agitiltrcl when fiM SW~ iII bhe Thr boy was dental waiting room. His tlyskinesia was plainly apparenb. .He resistant a.IId evasive in answering questions, ilespit,e parental prompting. volunteered the information that, he “liked t,o read and play by himself,” in group activities with and that, he did not. “ caye much ” about Imrticipating other children in his class. The mother seemed to I)e a somewhat. inadequate person, relying on her hushand and son for even simple decisiws. Her estremely overprotect.ive attitude toward t.he child was specifically in evidence by her tletemkletl insistence OII thr unessedinl conmtic restoration of t.wo

chilq,etl atlterior teeth. The father. a husinessmall, was frequently required to leave his pla.ce of business to t~.~oml~a~y the l:oy to tlental nl)l)oirlttlletlts? the mother being unequal to this task. What little conttwl the father exercised over the 1:oy resulted frown a series of iil::~rp;litls.” iu which the l)oy ael~lom kept to his share (II’ the agreement. At the start of each visit. the boy reaffirmed his desire for treatment and his willingness to coo1)erat.e. His tlyskinesia increased ~~larketlly when he uws seated in the dental chair. however, ;~nd if an ;ittcmpt at treatmcrit. was made his incoordinate n1ovemeilt.s hecame so violent that it Imarne newssary to exercise restraint lest the 1:oy injure himself. This behavior seyuc~r~ewas Npeated at several visits over a long period. Alth~mgh the use of local anesthesia helped to diminish the reaction slightly? this patient has never been al)le to control the hyperkinetic effect to the extent of hecoming a fit. subject. for dental treatment. 1’1)the boy, t.hr dentist soon l~camc “Hitler.” and epithet he had fomc~~ly appliccl to an anthoritativr l)hysiothel.;l.pist who~t~ he ’ ’ hated. ’ ’ IV The manifestation of emotional conflict through yhysiologic mechanisms of the body has been widely observed. It does not seem unusual to find such reactions first evidenced through a particularly unstahlc ph,vsiologic system, if one is present. .Est.rcme emotional tension is a ul)iquitous experience in indivitluals whose fear of dental procedures is uncommonly exaggerated. This condition has With paCents who have had been described specifically as dentd nn.~iaty.~ no previous experience with dent.al l)rocedures, awl mow lx~rticularly with rest.ora.tive dentist.ry, tlental ansisty is amplified by fear of an unknown danger. It WRYbe said of both of the cases cit,ed that a tlental i\lGety. ol)erat.ing on an already labile neuromuscular system, produced the psyehomot.or effects tlescrihed. That the anxiety esl)erienced by 1)ot.h patients was largely of an unconscious nature may he deduced from the fact that, both espressctl :I. willingiicss to cooperate in treatment. procedures : their inability t.o do so as the result of unconscious anxiety was translated itlto violent i~lcoortlin;ttc ttlovements via the neuromuscular system. When more closely esamined a pertiuetlt difference is found to esist. hetween the two ca.ses. Case .1 resl)ontletl well to the use of local :lnest.hcsia. I II the absence of pain he eshibited little or no hyperkinetic reaction during treatment. It may lx inferred that a discreet fear of pain was the underlying ca,use ot’ this paGent’s dental anxiety, and that, other factors played little 01 no part in producing 6he psychomotor effects. Case 2, however, did not show any a.pprecial)le reduction in the hyperkinetic reaction over a, long period, despite at.tempts at reassurance and reeducation. and the use of local anesthesia. 111(~ontraat to C’ase1, the adjustment of t.his patient. to his halldi~a.1) was l)oor, as W:ISthe emotional environ-

1126

SIDNEY

IA. IfORO\VIT%

V The occurrence of similar motor reactions to attempts at dental treat.ment ha.s been described in IWO (*ilses of athetosis. 1t does not sc\?mpossible to explain the violence of the transition from the usnnl dyskincsia of t.hese patients to the sevel;e hyperkinrtic cffecia observed on the basis oCthe physical condition alone. Emotional environment has hecll suggested as ;I likely ailditional factor to t.he at.hetosis. Social requirements inv;~1*ial)ly ~lcman- ~hc demantls placed upon them. IJnquestionably much of the insecurily evident in athctoid pAient.s results directly from t,he neul’orllllsclll;lr disability, illltl may be cow&lerecl ill1 unavoidahle consequence of it. It. is clearly apparent. however, that the emc~Conal environment. of such patients has a clerl) and I)ervatling eff ccl on the personality. In varying degrtae 1x)t.h faef(>rs opcratc to prodncr the anGty and insecurity. In the first case descril)thd the cwaellent. filmily emotional background and high morale permitted rapid adjustment to a ~mparativtly discreet. manifestation of anxiety. A reverse condition existed in the second G~SC.in which an unhealthy family emotional environment resultetl in a iliffnse x1siet.y and acl.justmcnt an overwhelming insecurity which prerentccl il ny S:ltiSfilctOr;y when dent.al treatment Was attpmptecl. From the foregoing it. may 1~ coneMet tll;lt. ;I.tht>tosis,present to a Momparable degree in both patients. Was not the tlecisivr factor in t,he production of the estreme hyperkinetip reactions. Early emotional environmenl: had created anxiet,y st.nt.es which woe apparent. Prom the first in both cases, although one patient. was subscclnently able to clsereise a.11npprcciable ilnlontlt of control. These anxiety states acted as a. “t)“iqg~t*” mechanism iu setting off violent psychomotor effects through t.he medium of a labile neuromuscular system. Tnstruetor in The author wishes to express his indebtedness to -Dr. Ruth Moulton, Psychiatry, Columbia University, and Attending Physician, Presbyterian ‘ITospital, N’aw York, for her guidance and criticism in the preparat.ion of this paprr; also to Dr. Randolph K. Hyers, of tho Boston Children?s Hospital, who read the manuscript and ofl?ered swcral valuable suggestions.

PSTCHOMOTOR EFFECT

IN

ATIIKTOII~

L’ATIESTS

I127

References I. Report of the New York &ale Joint Legislatire Committ~cle to Study the Prol~I~~nrof Cerebral Palsy, Albany, 1948, IViliams. 2. Frantz, S.: The Cerebral Palsy Problenf, Xichigan State IL. J. 45: 1489, 1946. 3. Fhelps, W. M.: Characteristic. Psychologleal I’ariations in (.‘erebml Palsy, Serv. Chilrl 7: 10-14. .1948.

4. Kile, I. S.: “l’he Relation of Orthopedics to Personalitv , .T. A. 31. A. 84: M23, l!%. .5. Smith, S. R.: FIements of Orthopetlie Surgery, Wood 6; ._ _, Raltimore, 1937, Willianl (‘ompany. 6 Lord, 1;. lx.: Children Handicapped by Cerebral Palsy. Psxchological Factorti ill Management., Sew York, 1937, Commonwealth Fond. An FIsploratory Psychological Study of Crippled Chilthr~, 7. Kammerei-, H. C.: Psvchol. Rev. 4: 47, 1940. 8. Coriot, i: H.: Dental Anxiety, Psyvehoanatyt. Hev. 33: 305X7, 1946. 20

J'hs~

35~11 STREKT.