Automatic Obedience
Automatic obedience is the carrying out of every instruction given, regardless of its content or consequences, even when doing so is uncomfortable, undignified, or repeatedly painful. The patient continues to comply with an instruction even after direct, repeated experience of an unpleasant consequence, without adjusting their behaviour to avoid it.
This has traditionally been demonstrated with a specific bedside test: the patient is asked to put out their tongue and it is then pricked with a pin; a patient with automatic obedience will continue to put their tongue out on request despite the repeated unpleasant consequence, whereas most people would quickly stop complying.
Also known as
- Command automatism
- Used by some authors as a simple synonym for automatic obedience, and by others for a broader syndrome combining automatic obedience with waxy flexibility, echolalia, and echopraxia; the term's meaning should be clarified whenever it is used.
Recognition features
- Compliance with instructions regardless of their content, including instructions that are uncomfortable, undignified, or repeatedly result in an unpleasant consequence
- The failure to adjust behaviour despite repeated unpleasant experience is a striking and specific feature
- Most commonly seen in catatonia, though also occasionally seen in dementia
- Distinct from ordinary cooperativeness, given the degree and indiscriminate nature of the compliance
Eliciting it at interview
- With appropriate care and consent, instructions of graded harmlessness can be given to observe the degree and consistency of compliance
- Note whether the patient continues to comply with an instruction after a mildly unpleasant consequence has already occurred once, since persistence despite this is the more specific and telling sign
- Consider automatic obedience alongside other related catatonic signs, such as waxy flexibility, echolalia, and echopraxia, since these are sometimes described together as part of the same broader clinical picture, although terminology for this grouping varies between authors
Distinguishing features
- Differs from ordinary cooperativeness in the indiscriminate nature of the compliance and its persistence despite direct experience of an unpleasant consequence
- Differs from cooperation (Mitmachen), in which the body can be passively moved into any position, whereas automatic obedience concerns compliance with verbal instructions specifically
- The precise relationship between automatic obedience and the broader tetrad sometimes called command automatism is not agreed on across all authors, and the specific meaning intended should be clarified
Common misconceptions
- That automatic obedience simply reflects an unusually compliant or agreeable personality; the hallmark is the failure to adjust behaviour even after a clearly unpleasant consequence has already occurred
- That automatic obedience is exclusive to schizophrenia; it is most common in catatonia but is also occasionally observed in dementia
Related phenomena
Waxy Flexibility · Echolalia · Echopraxia · Forced Grasping
Related syndromes
Diagnostically relevant to
Schizophrenia (catatonic presentations) (links open the DSM-5 Learning Lab)
Practice this
A patient complies with every verbal instruction given during an examination, including one that produces an uncomfortable sensation, and continues to comply with further instructions in the same way immediately afterward, without any adjustment in response to that unpleasant experience. What is this? · A patient follows straightforward, reasonable instructions during an examination but declines an instruction that would cause obvious pain, explaining that it would hurt. Before revealing the answer: is this automatic obedience? · A patient shows an unusual degree of compliance during a motor examination. Before revealing the answer, decide what distinguishes automatic obedience from Mitmachen and Mitgehen. · A patient's behaviour does not match a given instruction. Before revealing the answer, decide what distinguishes forced grasping from automatic obedience. · You want to test a patient for automatic obedience. Before revealing the answer, decide how you would go about it. · Explain why the failure to adjust behaviour after an unpleasant consequence, rather than simply a high degree of cooperativeness, is what actually defines automatic obedience.
Illustration
A clinician asks a patient with catatonia to close a drawer, and although the drawer sticks and pinches his finger slightly each time, he continues to close it exactly as instructed each time he is asked, without protest or hesitation, showing no sign of adjusting his response to avoid the minor discomfort.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 8, 'Motor Disorders'.