A captivating encounter with an unorthodox psychiatrist, Dr Richard Hunter, in a north London hospital gave Daniel Rogers inspiration for his book Motor Disorder in Psychiatry (Reference Rogers1992: p. xii). In it, Rogers utilises the Necker cube phenomenon to illustrate the rival psychological and neurological paradigms in the approach to the same psychiatric phenomena (Fig. 1). Rogers eloquently applies this concept to multiple clinical examples, such as the similarity in presentation reported between encephalitis lethargica and dementia praecox/schizophrenia, when these conditions were first described.

FIG 1

An adaptation of Rogers’ illustration of the Necker cube phenomenon demonstrating the conflicting paradigm views on how motor disorders in psychiatric disorders could be approached.

Quoting the literature and his own clinical observations, Rogers promotes the validity of a neurological approach in both academic and clinical spheres to encourage advancement of our understanding in this persistently elusive field.

Rogers begins by highlighting the views proposed by eminent 19th-century psychiatrists such as Henry Maudsley and Wilhelm Griesinger, who originally endorsed psychiatric disease as a disorder of brain. He then describes how the 19th-century neurology-dominant views of psychiatry changed over the course of the 20th century, i.e. that the approach to psychiatric disorders shifted towards the investigation of abnormal mental state rather than cerebral dysfunction. In doing so, Rogers provides a historical background to these opposing views, encapsulated beautifully by Oliver Sacks as soulless neurology versus bodiless psychology. Rogers offers a chronological account of the constant back and forth between these two paradigms by methodically dissecting the published literature on movement disorders reported in psychiatric patients over the preceding two centuries. He elaborates on how scientists using a psychoanalytical framework suggested new ways of analysing movement disorders by attributing psychological meaning. Examples of these now outdated and unhelpful interpretations include the interpretation of flexed posture as repressed sadism, of drooling as ‘displaced’ seminal emission (p. 2), protrusion of the lips (schnautzkrampf) in catatonia as the expression of contempt (p. 11), blepharospasm as an inability to face reality and torticollis as an inability to face the future (p. 18).

The philosophical basis of psychiatry has always been debated. Although no longer as widely accepted, Descartes’ proposal of mind–body dualism (Robinson Reference Robinson and Zalta2020) in the early 17th century played a vital role in our early understanding of the relationship between mind and body, influencing theoretical models which later contributed to development of two major treatment approaches in psychiatry – the biological and the psychological. Freud’s psychoanalysis had a profound impact on the practice of psychiatry in the late 19th and early 20th centuries, shifting the focus of psychiatry away from a more brain-based/biological understanding to one related to psychological conflicts and further contributing to the divide between neurology and psychiatry. However, this gap was later bridged with the invention of electroencephalography (EEG) by Hans Berger in 1924, which allowed objective assessment of brain activity, including emotional state, attention and memory, in real time, further broadening understanding and insight into neuropsychiatric disorders (Haas Reference Haas2003).

Although psychological approaches started to lay the foundation of contemporary psychiatry from the early decades of 20th century, the study of pathophysiology underlying mental disorders was also considered fruitful by those who attempted to bridge these two fundamentally opposing views. Accordingly, Rogers addresses the paradoxical organic versus functional dichotomy, arguing that a dichotomous distinction without any connection between the two radically opposing poles is logically flawed. Rogers demonstrates the development of the conflicting rival paradigms of the Necker cube over time, whereby different methods are utilised, including the development of distinct terminologies by neurologists and psychiatrists, in an attempt to understand a shared observation.

Rogers focuses on catatonia, dystonia and extrapyramidal symptoms, exploring different theories from the likes of Kraepelin (Reference Kraepelin, Barclay and Robertson1919) and Kleist (Reference Kleist1960). Aetiological factors reviewed range from purely psychological to iatrogenic and brain pathologies. Other topics discussed vary from the evolution of the historical concept of institutional neurosis and the significance of the basal ganglia in movement disorders through to the post-antipsychotic (post-neuroleptic) era of the 1950s and the neurotransmitter revolution in the 1960s. Rogers critically appraises the evidence that compares motor disorders observed in psychiatric patients taking antipsychotics with such disorders in those who were antipsychotic-naive, elucidating the considerable overlap between the two. He concludes that the contribution of antipsychotic medication to the development of motor symptoms cannot be considered in isolation from the motor disorders observed in psychiatric patients.

Rogers goes on to provide an in-depth evidence-based analysis of movement disorders in the context of obsessive–compulsive disorder, hysteria, neurodevelopmental conditions and antipsychotic-induced movement disorders. He also presents the findings of his own impressive research projects, providing insight into the variety of movement disorders identified in 100 in-patients with schizophrenia, as well as in a cohort of 236 with intellectual disabilities. Rogers subsequently discusses his own findings and those of others to address the abnormalities observed in tone, posture, speech and motor activities (such as akinetic mutism) in psychiatric patients.