Hand behaviors in Mental Disorders: Psychopathology & Guidelines according DSM-5 (2013), DSM IV (1994) & ICD-10 (1992)!
Hand behaviors (read: hand gestures, hand movements, hand signs, etc.) in different cultures may imply different meanings, this is even seen in the deaf cultures around the world which communicate using different hand sign languages. But sometimes hand behaviors are recognized to have univeral value. This is for example illustrated by the role of hand behaviors in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV + DSM-5, presented in 2013 by the American Psychiatric Association) & the International Statistical Classification of Diseases and Related Health Problems (ICD-10 chapter V, presented in 1992 bij the WHO), which are today recognized to represent the world's leading sources for the classification of psychiatric disorders. Interestingly, both diagnostic tools make various references to body language behaviors involving the hands. This article presents an overview of the most significant hand beviors mentioned in both systems, which include a wide range of extraordinary disorders, e.g social phobia, OCD, ADHD, autism, depression & psychotic disorders!
Behavior specialists in psychology are generally more interested in answering the question 'why do people use hand gestures?' instead of answering the question 'what is the meaning of a specific gesture?', because the context is usually decisive regarding the motives why people start using body language.
Therefore it is crucial to understand that the listed hand behaviors in isolation (from other significant contextual clues) should not get associated with any mental disorder directly. This implicates that context should always become decisive in the process of assessing the significance of these hand behaviors!
CONTENT - 16 HAND BEHAVIORS IN MENTAL DISORDERS (according DSM IV/5 and/or ICD-10):
• I - COLD, CLAMMY HANDS: Generalized Anxiety Disorder, Social Phobia (Social Anxiety Disorder)
According the DSM IV represent cold clammy hands (combined with shaky hands/trembling hands/tremors) an observable sign for anxiety, which explains why it became associated with Generalized Anxiety Disorder [DSM-IV code: 300.02].
In DSM 5 & ICD-10 this hand behavior is not explicitly mentioned, but there is consensus that cold, clammy/sweaty hands & shaking hands represent a classic observable sign for anxiety.
Alternatively, cold, clammy hands may also represent an observable sign in Social Phobia [DSM-IV code: 300.23].
• II - Hand-washing compulsions: Obsessive Compulsive Disorder (OCD)
According the DSM-IV & DSM 5 represent hand-washing compulsions (resulting in raw skin due to contamination fear) is recognized as a typical feature of Obsessive Compulsive Disorder [DSM-IV & DSM 5 code: 300.3]; fear of being contaminated by shaking hands or by touching objects others have touched is also a typical example of accessory behavior. In ICD-10 hand washing is also described as a typical behavior in Obsessive Compulsive Disorders [ICD-10 code: F42].
Short movie - Daily life with hand washing compulsions (OCD):
• III - SKIN PICKING DISORDER: Excoriation (Impulse Control Disorder)
In DSM 5 a seperate category has been created for skin picking (resulting in significant distress or impairment in social/occupational functioning), which represents a clue for an OCD related impulse control disorder named excoriation [DSM 5 code: 698.4]. In ICD-10 this disorder is not listed (yet).
In DSM-IV excoriation was also listed for Amphetamine-Induced Psychotic Disorder [DSM-IV code: 292.12].
A Fox11 News LA report on skin picking disorder:
• IV - HAIR PULLING DISORDER: Trichotillomania (Impulse Control Disorder)
According the DSM-IV can excessive hair-pulling behavior (resulting in noticable hair loss + distress or impairment in social/occupational functioning) represent a clue for an Impulse Control Disorder named Trichotillomania [DSM IV code: 312.39]. In ICD-10 Trichotillomania is classified under the Habit & Impulse Disorders [ICD-10 code: F63.3].
The (awesome) BBC video below concerns a selfie project documenting a young woman's battle with her trichotillomania hair-pulling disorder; the original video has been watched almost six million times on YouTube:
• V - (Out of control) FINGER TAPPING/FIDGETING: Attention Deficit Hyperactivity Disorder (ADHD)
According the DSM-IV & DSM 5 can out of control hand tapping (or finger fidgeting with- or without objects) represent a clue for ADHD [DSM-IV & DSM 5 code: 314.01]. In ICD-10 this disorder is not listed (yet).
Alternatively, according DSM-IV & DSM 5 out of control finger fiddling, striking fingers, playing with hands or hand waving represents a clue in Stereotypic Movement Disorder [DSM-IV code: 307.3], a disorder that interferes with normal activities or results in bodily injury. In ICD-10 finger flicking represents a feature in Stereotypic Movement Disorder [ICD-10 code: F98.4]. NOTICE: The person may develop methods of self-restraint (such as: holding hands inside shirts, trousers, or in pockets) in an attempt to control the self-injurious behaviors.
According DSM-IV so-called atheoid finger movements (which are characterized by slow, involuntary, convoluted, writhing movements of especially the fingers or hands) represent a clue for Tic Disorders [DSM-IV code: 307.20]. In ICD-10 this disorder is not listed.
The video below a typical example of athetoid finger movements:
• VII - TREMORS OF OUTSTRETCHED HANDS: Medication-Induced Postural Tremor, withdrawal states (related to e.g: alcohol, cannabis, sedative-hypnotic)
According the DSM 5 (+ DSM-IV) a so-called condition named Medication-Induced Postural Tremor [DSM code: 333.1] - such as: Alcohol Withdrawal [DSM-IV code: 291.8] & Sedative, Hypnotic, or Anxiolytic Withdrawal [DSM-IV code: 292.0] - is featured with a tremorn with a regular, rhythmic oscillation of the limbs (most commonly hands and fingers) with a frequency of between 8 and 12 cycles per second. It is most easily observed when the hands are stretched out. This is a typical phenomenon due to e.g. antidepressant medications & antipsychotics.
In the ICD-10-CM system, this hand behavior is known under the same name: Medication-Induced Postural Tremor [ICD-10 code: G25.1]; also, the same type of tremors also likewisely gets associated with withdrawal states related to alcohol [ICD-10 code: F10.3] or cannabis [ICD-10 code: F12.3], or due to a sedative-hypnotic withdrawal state [ICD-10 code: F13.3].
The video below demonstrates how essential tremor affects the whole person-physically, psychologically, socially, and emotionally:
• VIII - HAND FLAPPING/FINGER FLICKING: Autism Spectrum Disorder, Delirium
According the DSM 5 is hand flapping (or: repetitive hand shaking, hand clappping, finger flicking, finger twisting) a common behavior assocated with Autims Spectrum Disorder [DSM 5 code: 299.00] (in DSM IV hand flapping & finger twisting was listed for Autistic Disorder [DSM-IV code: 299.00] & Asperger's Disorder [DSM-IV code: 299.80]). In the ICD-10 system, hand flapping is likewisely associated with Pervasive Developmental Disorders, including: Childhood Autism [ICD-10 code: F84.0] and overactive disorder associated with mental retardation and stereotyped movements [ICD-10 code: F84.4].
In rare cases hand flapping may also gets associated with Delirium due to a general medical condition [DSM IV & 5 code: 93.0], specified as 'Asterixis': the flapping movement of the hyperextended hands, was originally described in hepatic encephalopathy but may also be found in association with other causes of Delirium; this concerns a condition that can be recognized as a tremor variant.
In the video below peditrician Dr. Sara Connolly explains when to get worried about hand flapping in children:
• IX - HAND BITING: Autism Spectrum Disorder, Stereotypic Movement Disorder
According the DSM 5 is hand biting a well-known behavior assocated with Autism Spectrum Disorder [DSM 5 code: 299.00] (in DSM IV hand biting was listed for Autistic Disorder [DSM IV code: 299.00]).
Hand biting also gets listed as a common feature in Stereotypic Movement Disorder [DSM IV & DSM 5 code: 307.3].
Hand biting was not yet listed in the 1993's ICD-10 system, however later it became listed as 'habitual hand biting' inside a long list of other and unspecified special symptoms or syndromes, not elsewhere classified [ICD-10 code: 307.9].
• X - HAND WRINGING: Rett syndrome (Autism Spectrum Disorder), agitation in Major Depressive Episode
According the DSM-IV hand wringing (which may look like hand washing, representing midline hand movements) can represent a very typical clue for stereotyped hand movements in Rett Syndrome [DSM-IV code: 299.80]. In ICD-10 hand wring is also listed as a typical behavior in Rett syndrome [ICD-10 code: F84.2], which became classified in DSM 5 under the Autism Specturm Disorder.
Hand writing also gets listed as a common feature in agitation in Major Depressive Episode [DSM IV code: 296.40].
The video below present an example of hand wringing in a young girl with Rett syndrome:
• XI - (EXCESSIVELY) POOR HANDWRITING: Specific Learning Disorder with Impairment in Written Expression
According DSM 5 excessively poor handwriting (in the presence of other impairment in written expression) can represent a clue for a Specific Learning Disorder with Impairment in Written Expression [DSM 5 code: 315.2; in DSM-IV it was named: disorder of written expression]. In ICD-10 it is named: Disorder of Written Expression [ICD-10 code: F81.81].
A disorder in spelling or handwriting alone, in the absence of other difficulties of written expression, generally does not qualify for a diagnosis of disorder of written expression. If poor handwriting is due to impairment in motor coordination in isolation, this presents a clue for Developmental Coördination Disorder.
In the video below clinical psychologist Dr. Kimberly Williams describes the potential impact (+ cause) of a non-verbal learning disorder:
Additionally, there are a few other hand behaviors which have been associated with various types of psychopathology which have been mentioned inside the DSM IV/5 system presented by the American Psychiatric Association, or the WHO's ICD-10 system for the classification of mental disorders:
• XII- Small handwriting (micrographia) represents a sign of Neuroleptic-lnduced Parkinsonism [DSM-IV code: 332.1].
• XIII- Loss of the ability to identify objects placed in their hands by touch alone is listed in DSM-IV as a significant sign in Dementia [DSM-IV code: 294.8].
• XIV Presence of involuntary choreiform movements, typically of the hands is described in ICD-10 as a significant sign in Dementia in Huntington's disease [ICD-10 code: F02.2]. The patient may attempt to conceal them by converting them into a voluntary action.
• XV- Delayed developement of hand dominance has been associated in DSM-IV with Autistic Disorder [DSM-IV code: 299.00].
• XVI- Loss of previously acquired purposeful hand skills (between ages 5 and 30 months, with the subsequent development of characteristic
stereotyped hand movements resembling hand-wringing or hand washing) has been associated in DSM-IV with Rett Syndrome [DSM-IV code: 299.80].
• XVII- Alien hand syndrome manifests in feeling that one's hand is possessed by a force outside of ones control. The syndrome typically arises after trauma to the brain, after brain surgery or after a stroke or an infection of the brain. A person with the alien hand syndrome can feel sensation in the affected hand but thinks that the hand is not part of their body and that they have no control over its movement, that it belongs to an alien [ICD-9 code: 781.8].