Psychogenic Movement Disorders

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42 Psychogenic Movement Disorders

Diana Apetauerova

Clinical Vignette

A 35-year-old woman with a medical history of depression presented with intermittent head tremor. Several months ago while driving, with her seat belt on, and stopped at a traffic signal she had a motor vehicle accident (MVA) when her car was rear ended. She had no immediate overt injuries, but did complain of mild neck pain after that. Subsequently, just 3 weeks later, she first noted tremor. Her tremor was fairly persistent and did not improve after drinking alcoholic beverages or disappear at night. She “had to leave work” due to this tremor; she then filed formal litigation against the offending driver. Her family history included a younger brother with dystonic cerebral palsy. This patient used fluoxetine (Prozac) long-term for her depression.

This patient appeared very anxious; however, her general physical examination was unremarkable. Her neurologic examination demonstrated an intermittent shaking horizontal “no–no” head posture as well as “yes–yes” vertical tremor of her head. The tremor continually changed in frequency as well as amplitude; there was no consistent pattern evident; that is, it was consistently inconsistent. She had no dystonic posturing or hypertrophy of any neck muscles. Her tremor became very prominent while discussing the details of the MVA and completely disappeared when she was deliberately distracted. Similarly, the tremor was totally absent during other portions of the neurologic examination. However, her muscle strength testing also demonstrated consistently inconsistent “weakness” of the “give way” type typical of nonorganic secondary gain patients. The remainder of her examination was unremarkable. She did not have any tremor in other body parts, nor any cogwheeling, rigidity, or signs of dystonia. While ambulating, her head tremor again became very prominent.

Laboratory testing for Wilson disease, thyroid, vitamin B12 level, head and neck magnetic resonance imaging (MRI), and magnetic resonance angiography were all normal. With her consistently inconsistent neurologic findings, a diagnosis of psychogenic tremor was suspected. Several treatment options including propranolol, anxiolytics, and antidepressants were tried without either objective or subjective improvement. Later, after undergoing psychotherapy, she experienced a sudden and complete remission of these symptoms.

Psychogenic, psychosomatic, hysterical, or functional movement disorders are conditions related to an underlying psychiatric illness with no evidence of any organic etiology. One has to be very cautious. There is a major inherent difficulty whenever one entertains a diagnosis of a psychogenic movement disorder as studies demonstrate that this is a too common and poorly documented diagnosis, in that up to 30% of patients diagnosed with psychogenic disorders eventually are found to have an organic neurologic illness, Because, with just a few exceptions, most movement disorders have no specific diagnostic laboratory or imaging study available, beyond clinical observation, there is a temptation by the uninitiated to label a patient hysterical when the clinician cannot arrive at a definitive organic diagnosis. An important diagnostic caveat is for the evaluating physician to not rush to judgment when the patient’s findings do not initially fit a specific diagnostic set, such as pill-rolling rest tremor, cogwheel rigidity, masked facies, and en bloc walking as is typical of Parkinson disease. Astute clinicians often use a “tincture of time” to prospectively and carefully follow patients by repeated clinical evaluations. Here one monitors the individual patient for the gradual development of recognized classic signs of an evolving and well-recognized neurologic process. Barring the later clinical evolution of symptoms and findings into a more classic organic movement disorder, the clinician will gradually acquire information from the patient or family to become more comfortable with the importance of underlying psychogenic factors.

A variety of underlying psychiatric diagnoses are found in patients with psychogenic neurologic movement disorders; these include various somatoform and factitious disorders, malingering, depression, anxiety, and histrionic personality disorders. Although a specific psychiatric diagnosis cannot always be confirmed for these various abnormal and consistently inconsistent motor symptoms, despite the clinician’s high suspicion of psychogenicity, an emotionally based diagnosis is not totally precluded. Often it is only time and a cautious diagnostic approach that will allow one to sort out the majority of these challenging patients’ specific diagnosis. In young women, one has to be particularly careful to not overlook sexual abuse, particularly incest.

Psychogenic tremor, dystonia, myoclonus, chorea, and parkinsonism are the typical means for a functional movement disorder to present and are particularly common in women (Fig. 42-1). These patients usually have multiplicity and variability of symptoms superimposed on a significant psychiatric background. The neurologic findings do not fit a specific diagnostic set typical of the classic organic movement disorders. These factitious patients present with movements that are consistently inconsistent and are particularly liable to change or decrease during distraction. Frequently, patients with psychogenic movement disorders display uneconomic postures demonstrating a most exaggerated effort during examination that may also produce fatigue. They may demonstrate marked slowness when asked to perform certain tasks such as rapid alternating movements.

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Figure 42-1 Psychogenic movement disorder, pseudochoreoathetosis.

Therapeutically, psychogenic movement disorders often respond to placebo or suggestion.

Etiology

Because the etiologies of psychogenic movement disorders are unknown, no anatomic correlation can be made. It is totally conjectural as to whether any neurochemical interplay exists, or will later be recognized, between the effect of the presumed underlying psychiatric condition and the patient’s clinical presentation.

Clinical Presentations

Psychogenic Dystonia

Dystonia is an involuntary, sustained muscle contraction causing repetitive twisting and abnormal postures. Most patients with dystonia have no identified mechanism, although some have a genetic basis. Because no specific test for organic dystonia exists, the diagnosis of psychogenic dystonia is very difficult to initially confirm. There is a broad clinical presentation for the organic dystonias. And the neurologist must always take such into consideration, keeping an open mind before making a psychogenic diagnosis.

Patients with psychogenic dystonia may present with foot or leg involvement, a distribution that is relatively unlikely but not exclusive of an organic adult-onset idiopathic dystonia. An important clue to a diagnosis of a psychogenic dystonia is the presence of symptoms at rest; this often helps to differentiate such individuals from those with an action-specific organic dystonia.

Psychogenic Tremor

Tremors are rhythmic, bidirectional, oscillating movements resulting from contraction of agonist and antagonistic muscles. Tremors can be resting, postural, or action.

Psychogenic tremor usually varies in frequency and amplitude, is complex, occurs at rest, during various postures, and with various actions. Psychogenic tremor often has amplitudes unlike that of even midbrain tremor. It typically lessens with distraction.

Psychogenic Myoclonus

Myoclonus is defined as brief, shocklike movements caused by muscle contraction or lapses in posture. The frequency, amplitude, body distribution, symmetry, and course differ with various etiologies. Psychogenic myoclonus decreases in amplitude during distraction and often occurs at rest, in contrast to organic myoclonus, which decreases at rest.

Psychogenic Parkinsonism

Parkinsonism is a symptom complex consisting of resting tremor, rigidity, bradykinesia, and impaired postural reflexes. Psychogenic tremor varies in frequency and rhythmicity, remitting with distraction. Rigidity related to psychiatric problems consists of voluntary resistance without any evidence of cogwheeling. As with other psychogenic movement disorders, the symptoms of psychogenic parkinsonism lessen with distraction. Gait is atypical, with extreme or bizarre postural instability.

Differential Diagnoses

Psychogenic movement disorders have certain common characteristics, such as acute onset, static course, spontaneous remissions, consistently inconsistent character of their movements in amplitude, frequency, distribution, and a selective disability. Furthermore, these psychiatrically affected individuals are unresponsiveness to appropriate medications, may sometimes respond to placebo, have their movements increase with attention, while these same adventitious movements decrease with distraction. A remission may occur with psychotherapy, once a specific psychopathology is diagnosed. The clinician strives to make a distinction between these psychogenic clinical presentations and those of organic movement disorders. It is very often a most challenging diagnostic algorithm and sometimes may take several years to confirm.

Certain factors support the possibility of a psychogenic movement disorder. This is particularly relevant when there is a patient history of multiple poorly defined, somatic complaints. Other supportive evidence for an emotional basis includes specific findings on neurologic examination. These include a nonanatomic sensory loss such as when one places a tuning fork on the forehead and the patient states he or she does not feel it when it is tilted to the left but does so when tilted to the right, while the examiner maintains the instrument’s base in the precisely same anatomic spot for each testing. Similarly, a consistently inconsistent weakness and a seemingly deliberate slowness of movement are also typical of psychogenic movement disorders.

Questioning the individual or family to potentially uncover possible secondary gain are also important. This is especially true when one determines that there is a pending litigation or workman’s compensation action. On some occasions, psychiatrically ill patients use a family member or friend with an organic movement disorder to serve as a subconscious model for their own adventitious movement or gait disorder. Thus, one may sometimes find a positive family history by meeting with and observing family members important in the individual’s daily life. These encounters may provide a good means for establishing the true identity of the patient’s problem. Such a meeting may be overwhelming when one identifies the precise model for the specific movement. Some patients are truly great actors!

Diagnostic Evaluation

The diagnosis of psychogenic movement disorder usually requires both a neurologist and a psychiatrist as well as a direct meeting with family members. The initial step is a detailed clinical history and examination, review of current and previous medications, and subsequent exclusion of a true organic movement disorder. Diagnostic tests follow clinical assessment and may include brain MRI, serum ceruloplasmin and urine copper excretion, thyroid functions, and other tests based on clinical suspicion. The diagnostic evaluation may also include an appropriate trial of specific medications typically used for various organic movement disorders and tailored to the patient’s clinical picture. After these steps are taken, and certain clinical suggestions of psychogenicity are defined, a diagnostic psychiatric evaluation is needed. However, the definition of a psychiatric illness still does not absolutely prove that the movement disorder has a psychogenic basis as patients with psychiatric disorders of course also develop organic neurologic diseases.

Thus, careful neurologic as well as psychiatric follow-up is often mandated. Wilson disease is a good example of patients presenting with seemingly bizarre movements that have led to psychiatric diagnosis early on. Careful attention to search for a Kayser–Fleischer ring when looking at the patient’s iris and obtaining copper screening studies may occasionally uncover this important but very rare movement disorder. There is no more grateful patient.

Treatment And Prognosis

These patients present a therapeutic challenge equal to the diagnostic challenge that led to a proper diagnosis. Treatment of these individuals is often very difficult. No specific treatment protocols exist. Periodic neurologic follow-up with the same neurologist, in conjunction with psychotherapy, is often necessary to alleviate residual concerns that an organic illness is present. These visits will also provide reassurance to the patient and subsequently lead to a reduction or remission of the adventitious motor symptoms. Careful neurologic follow-up can be exceedingly reassuring for not only the patient but often the physician. It is not appropriate to make a psychogenic diagnosis without providing for careful follow-up. Ongoing psychotherapy and physical therapy are important, as is treatment of the underlying psychiatric conditions (antidepressants, anxiolytics, etc.). Finally, the use of placebo is debatable. Some physicians and patients interpret this as confrontational. Unfortunately, some patients resist accepting both the diagnosis and psychiatric treatment.

Prognosis depends on the psychodynamic specifics underlying the movement disorder. Generally good prognostic signs include acute onset, short duration of symptoms, healthy premorbid functioning, absence of coexisting organic and psychogenic disease, and presence of an identifiable stressor.

Future Directions

When specific laboratory tests, possibly neurochemical or autoimmune in type, become available for the diagnosis of organic movement disorders, psychogenic movement disorders will be easier to confirm. More research in the field of neurotransmitters, more specific brain studies, such as functional MRI, and genetic testing will eventually aid the understanding of this complex and difficult therapeutic problem. It is not out of the question that eventually some new previously misunderstood organic movement disorders will be identified in some of these individuals.

Additional Resources

Fahn S, Williams D. Psychogenic dystonia. Adv Neurol. 1988;50:431-455.

Halle M, Fahn S, Jankovic J, et al. Psychogenic Movement Disorders. Neurology and Neurosurgery. Baltimore, MD: Lippincott Williams & Wilkins; 2006.

Koller WC, Marjama J, Troster A. Psychogenic movement disorders. In: Jankovic J, Tolosa E, editors. Parkinson’s Disease and Movement Disorders. Baltimore, MD: Williams & Wilkins; 1998:859-868.

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