Disorders of Expressive Movement
Expressive movements are the face, hand, and body movements that normally accompany and communicate emotion, and they vary enormously with mood, culture, and individual personality. A disorder of expressive movement is a disturbance in the range, quality, or appropriateness of these movements, ranging from the diminished, flattened expression of depression, through the stiff, mask-like face and scanty gestures of catatonia, to the exaggerated, expansive gestures of mania.
This has traditionally been recognised as a broad category spanning several very different underlying illnesses, unified only by the observation that expressive movement is disturbed; the specific quality of the disturbance (reduced, stiff and masked, or exaggerated) is what points toward the underlying condition.
Also known as
- Ointment face
- A flat, full, expressionless face with a greasy appearance, classically described in post-encephalitic parkinsonism, with a similar but less greasy quality in Parkinson's disease itself.
Recognition features
- In depression, a generally limited range of expressive movement, with a sad or anxious cast to the face
- In catatonia, a stiff, mask-like facial expression with scanty body movement, though the eyes may remain paradoxically lively
- In mania, exaggerated, wide, expansive gestures accompanying a cheerful, overactive manner
- Distinguished from a morbid expression of emotion (such as affect blunting) in that this concerns the range and quality of physical, bodily movement specifically, rather than the emotional display considered more broadly
Eliciting it at interview
- Observe the range and quality of facial expression and gesture across the interview, noting whether it is generally reduced, stiff, or exaggerated relative to what the content would suggest
- In a stiff, mask-like presentation, check specifically whether the eyes retain liveliness despite reduced facial movement elsewhere, a recognised pattern in catatonia
- Ask family or carers whether the person's expressive movement seems changed from their usual pattern, since gradual changes can be easy to miss within a single assessment
Distinguishing features
- Differs from psychomotor retardation, which concerns a global slowing of all movement and thought, whereas this concerns specifically the range and quality of movements that express emotion
- Differs from affect blunting, a morbid expression of emotion concerned with emotional display broadly, whereas this is specifically about observable expressive movement
- The specific quality of the disturbance (diminished, stiff and masked, or exaggerated) helps distinguish depression, catatonia, and mania from one another
Common misconceptions
- That a stiff, mask-like face always indicates emotional flatness on the inside; in catatonia the eyes are often noted to remain lively, suggesting the inner emotional state may not be as flat as the face suggests
- That reduced expressive movement always reflects severity of illness alone; some patients with depression consciously try to compensate for reduced facial expression by smiling, which can mask rather than reveal the underlying state
Related phenomena
Psychomotor Retardation · Smiling Depression · Lability of Affect · Ecstasy
Practice this
A patient with severe depression sits with a permanently sad expression, makes almost no spontaneous hand gestures, and moves slowly and stiffly even when trying to express how she feels. What is this? · A patient's face and voice both convey markedly less emotion than expected throughout the interview, including reduced vocal tone variation, and this is not confined to any specific pattern of physical gesture; the patient does not notice any change in themselves. Before revealing the answer: is this a disorder of expressive movement? · A patient shows a reduced range of movement accompanying their emotional expression. Before revealing the answer, decide what distinguishes a disorder of expressive movement from blunting of affect. · You are assessing a patient for a possible disorder of expressive movement. Before revealing the answer, decide how you would assess for this. · Explain why the specific quality of a disorder of expressive movement (diminished, stiff and masked, or exaggerated) is clinically useful information.
Illustration
A 50-year-old man with catatonia sits with a stiff, unmoving face throughout an interview, his gestures almost entirely absent, yet his eyes track the interviewer attentively around the room, a striking contrast that the assessing clinician notes carefully rather than assuming a uniformly blank inner state.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 8, 'Motor Disorders'.