Opinion
Mapping Psychomotor Behavior in the Brain
VIEWPOINT
Sebastian Walther, MD Abnormal psychomotor behavior is a core feature of
Department of psychotic and mood disorders. Disorganized and/or cata-
Psychiatry and tonic behavior is 1 of 5 DSM-5-TR criterion A symptoms
Behavioral Sciences,
for schizophrenia, while psychomotor retardation and/or
Vanderbilt University
Medical Center, agitation is 1 of 9 criterion A symptoms for a major de-
Nashville, Tennessee; pressive episode and 1 of 7 criterion B symptoms for a
and Translational manic episode. In addition, psychomotor abnormali-
Research Center,
University Hospital of
ties are associated features for several other disorders,
Psychiatry and including autism spectrum and neurocognitive disor-
Psychotherapy, ders. Crucially, abnormal psychomotor behavior is as-
University of Bern,
sociated with poor clinical and functional outcomes.1
Bern, Switzerland.
What qualifies as abnormal psychomotor behav-
Stephan Heckers, MD, ior? It refers to a person moving not enough, too much,
MSc or in an unusual fashion. Wernicke labeled these as
Department of hypokinetic, hyperkinetic, and parakinetic behaviors, re-
Psychiatry and
spectively. He proposed that their study is the royal road
Behavioral Sciences,
Vanderbilt University to mapping the neural basis of psychiatric disorders.
Medical Center, Wernicke distinguished 2 stages of processing motor-
Nashville, Tennessee. related information in the brain. The first stage in-
cluded complex volitional, affective, and cognitive as-
pects, which remain hidden from the observer, termed
“psychomotor.” The second stage was the generation of
motor output, resulting in an observable change in be-
havior, previously termed “motor.” Broca’s description
of motor aphasia and Hitzig’s and Fritsch’s cortical stimu-
lation experiments in dogs gave Wernicke confidence to
localize the second stage to the precentral gyrus and
inferior frontal cortex. He did not localize psychomotor
function but speculated that there is a pathway project-
ing from cortical regions containing concepts
(“Begriffe”) to the primary motor cortex.
For decades, we have accepted a standard model
of the motor system, in the tradition of Wernicke. The
motor strip (M1) takes center stage as the final output
region. Three subcircuits with distinct functions pro-
vide input to M1: (1) the basal ganglia circuit (M1-striatum-
thalamus-M1) modulates excitation and inhibition of
movements; (2) the cerebello-thalamo-motor circuit pro-
cesses sensorimotor dynamics, such as coordination,
timing, and sequencing; and (3) cortico-motor circuits,
including the ventromedial prefrontal cortex, anterior
cingulate cortex, supplementary motor area (SMA), M1,
and posterior parietal cortex, control psychomotor or-
ganization and speed.2
Neuroimaging studies in depression and psychosis
indicated that hypokinetic motor abnormalities, such as
Corresponding
Author: Sebastian catatonia or psychomotor retardation, were linked to
Walther, MD, altered resting-state functional connectivity or cere-
Translational Research bral blood flow in premotor areas and M1.3-5 Similarly, dy-
Center, University
Hospital of Psychiatry
namic resting-state connectivity in autism suggested that
and Psychotherapy, severity of repetitive motor actions was linked to less
University of Bern, flexible interactions between cortical (M1 and SMA) and
Murtenstrasse 21,
subcortical motor networks.6 Thus, both concepts and
3008 Bern,
Switzerland (sebastian. data on psychomotor behaviors indicated a role of SMA
walther@unibe.ch). and M1. However, the interpretation considered pre-
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frontal or limbic inputs to M1 to drive alterations from
normal motor control (ie, psychomotor disturbances).
This interpretation assumed energetically costly long-
range connectivity (eg, amygdala to M1) to be continu-
ously in play during psychomotor phenomena (Figure).
A recent study by Gordon et al7 radically revised the
standard model and redrew the M1 homunculus. Using
resting-state functional magnetic resonance imaging
data from 4 large cohorts with more than 8900 partici-
pants and intense resting-state mapping (>3 hours) and
precision functional mapping in 7 participants, the au-
thors failed to detect the textbook pattern of homoge-
neous connectivity with homotopic regions. Instead,
they found effector regions for hand, foot, and mouth
that share close connectivity to the contralateral M1 and
primary sensory cortex. Crucially, they detected, imme-
diately adjacent to effector regions, intereffector re-
gions (IERs), which have a distinct connectivity pat-
tern: increased connectivity to the SMA, cingulate motor
area, insula, striatum, thalamus, and cerebellum. The 3
IERs are located between the effector regions for hand,
foot, and mouth. Activation of these regions lacked
movement specificity but was seen during movement
planning. The authors suspected that IERs constitute a
somato-cognitive action system for planning, prepar-
ing, and controlling body movements.7 The proposed or-
ganization of M1 parallels findings from monkey stud-
ies indicating nearest-neighbor principles that allow
efficient coding for important behavioral repertoires lo-
cally at M1.8
The IERs orchestrate movement of the entire body,
including the integration of movement plans, urges, in-
teroception, somatosensory signals, and volition.7 All
these functions are impaired in psychomotor pathol-
ogy, including catatonia, psychomotor retardation, tics,
neurological soft signs, and functional neurological dis-
orders. An efficient design would place psychomotor re-
gions close to the motor regions to integrate multiple as-
pects of complex motor behavior. Local projections cost
less energy than long-range connections. These short-
range connections would be developed especially dur-
ing training processes and brain maturation when form-
ing complex psychomotor repertoires. If IERs are the
integrators of multiple sources of information shaping
motor behavior, these areas would be critical for
psychomotor behaviors in psychiatric patients: ambi-
tendency and negativism, posturing and stereotypies,
and stupor and mutism. Likewise, IERs should present
altered functional connectivity in individuals with psy-
chomotor retardation in depression or psychosis. Fur-
thermore, repetitive and enduring aberrant movement
repertoires, such as mannerisms, grimacing, or rituals,
are probably encoded in the IERs. Psychiatric neuroim-
aging studies should focus specifically on the precen-
tral gyrus, a previously undervalued area.
7
 Opinion Viewpoint

Figure. Traditional and Revised Model of Motor Strip (M1) Connectivity in Psychomotor Behaviors

Traditional model Revised model

Supplementary Primary Supplementary Primary
motor area motor cortex motor area motor cortex
Presupplementary Presupplementary
motor area motor area
Foot

Foot Sup

Hand
Hand
Med

Mouth Mouth
Mou
utth
t

Inf

Putamen Putamen
Thalamus Thalamus

Limbic Limbic
system system

Cerebellum Cerebellum

Psychomotor
Motor
Motor output

The traditional model suspected multiple unspecific inputs to the homotopically M1. Intereffectors are likely critical hubs to multiple psychomotor behaviors in
organized motor strip. The revised model includes specific intereffector regions mental illness, such as catatonia, neurological soft signs, or functional
that receive multiple inputs and orchestrate the motor effector regions within neurological disorders. Inf indicates inferior; Med, medial; Sup, superior.

Are we closer to a more sophisticated understanding of
psychomotor behavior? A refined neuroanatomical model of
psychomotor behavior will focus attention on this often-ignored
domain of psychopathology. To capitalize on the novel ideas of
mapping psychomotor function to the brain, we need to train cli-
nicians to assess psychomotor behavior in regular clinical care.
Likewise, precise mapping of psychomotor abnormalities with
instrumentation (eg, with wearable devices) will support a more
mechanistic understanding. In addition, a revised model of the
human motor system will facilitate the development of noninva-
sive brain stimulation techniques aimed at ameliorating psycho-
motor symptoms. Previous studies of psychomotor abnormalities
targeted the SMA or cerebellum,9,10 but maybe the precentral
gyrus is also a worthwhile target. The newly detected IERs in M1
might be 1 of the psychomotor pathways that Wernicke had
proposed.

ARTICLE INFORMATION
Published Online: November 22, 2023.
doi:10.1001/jamapsychiatry.2023.4290
Conflict of Interest Disclosures: Dr Walther
reported receiving personal fees from Neurolite,
Lundbeck, and Mepha for medical education events
outside the submitted work. Dr Heckers reported
receiving grants from the National Institutes of
Health outside the submitted work and was an
editor of the DSM-5-TR Schizophrenia Spectrum and
Other Psychotic Disorders section.
Additional Contributions: Michael Linkinhoker,
MA (Link Studio), created the figure and was
compensated.
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