Psychogenic Movement Disorders
Psychogenic movement disorders (also called functional or conversion disorders) are characterized by unwanted movements, such as spasms, shaking or jerks involving any part of the face, neck, trunk or limbs. In addition some patients may have problems with their speech (slurred, soft voice, gibberish, foreign accent), bizarre gait or difficulties with their balance that are caused by underlying stress or some psychological condition. A variety of blood, imaging and other tests are usually normal and do not reveal any physical (organic) cause that could explain these motor abnormalities. Most psychogenic movements are considered involuntary – performed without conscious awareness or effort. They can mimic organic movement disorders, such as tremor, dystonia, chorea, tics, myoclonus, stereotypies, parkinsonism and paroxysmal dyskinesias, manifested by intermittent, unpredictable spells or abnormal movements. Although a psychogenic movement disorder may resemble or accompany an organic disorder, a skilled and experienced neurologist should be able to differentiate the two types of movement disorders.
Diagnosis and Treatment
Understandably, the diagnosis of psychogenic (stress-induced) movement disorder is a delicate matter both for physicians as well as patients. Patients manifesting movements or other motor abnormalities that can be quite dramatic and disabling, do not readily recognize or acknowledge that these are stress-induced (psychogenic), and may disagree with the diagnosis. Some physicians feel uncomfortable openly discussing the nature of the disorder and may use terms such as "functional disorder" instead of psychogenic disorder. Most seasoned physicians, however, believe that it is in the patient’s best interest to be honest and to candidly disclose the diagnosis and discuss the psychological nature of the movement disorder. Patients should understand that they have a movement disorder, such as tremor or dystonia, but that in their case the disorder is not due to any damage to the brain, spinal cord or nerves, but it is a manifestation of how their bodies respond to stress. Most people accept the notion that stress can cause high blood pressure and that, when under stress, some individuals (even professional actors and public speakers) shake. Despite best efforts, however, some patients are not able to understand or appreciate the relationship between prior stress or an underlying psychological disorder, and they refuse to accept the link between any possible stress factor(s) and the onset of the movement disorder. In many cases it takes more time or even several visits before the patient begins to understand the relationship between stress, underlying psychological and psychiatric conditions, and the movement disorder.
There is no blood test or any other diagnostic test for psychogenic movement disorder. The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include but are not necessarily limited to the following:
- Abrupt/sudden onset
- Triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related)
- Manifesting exhaustion, excessive fatigue
- Paroxysmal, episodic, intermittent disorder
- Spontaneous remissions
- Movements disappear with distraction, maneuver or pressing on a particular spot, application of a tuning fork (along with suggestion)
- Presence of underlying psychiatric disturbances (depression, anxiety)
- Multiple somatizations and undiagnosed conditions
- Lack of emotional concern about the disorder (la belle indifference)
- Exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems
Other characteristics include:
- Inconsistent movements (changing characteristics over time)
- Movements and postures incongruous with recognized disease patterns in organic disorders
- Slurred speech, soft voice, gibberish, foreign accent
- Delayed and excessive startle (bizarre movements in response to sudden, unexpected noise or threatening movement)
- Presence of additional types of abnormal movements that are not known to be part of the primary or principal movement disorder pattern that the patient manifests
- Active resistance against passive movement
- Fixed posture
Psychogenic movement disorders may be difficult to treat, especially if they are diagnosed late or if there is unwillingness by the patient to accept the diagnosis. Indeed, patients with the best prognosis are those who initially accept the diagnosis and work with the movement disorder neurologist, psychologist, psychiatrist and physical, speech and occupational therapist in implementing a short-term and long-term therapeutic program. The diagnosis should be disclosed to patients in a manner that is empathetic and nonjudgmental.
Several critical points are worth emphasizing when discussing the diagnosis with the patient:
- The movement abnormalities are not deliberate but subconsciously generated (i.e. “you are not faking it”).
- The presence of the movement disorder does not mean a psychiatric disease (i.e. “you are not crazy”).
- The movements are real and can interfere with normal functioning.
- There is no evidence of brain, spinal cord or any other neurological damage.
- This is a treatable and likely curable disorder.
In addition to disclosing the diagnosis and exploring various potential psychodynamic factors that could have brought on this condition, it is also important to discuss the role of underlying depression and anxiety, even though many patients deny or resist these psychiatric diagnoses. Physical, speech and occupational therapy may be useful not only in improving physical and psychological functioning, such as activities of daily living, but also to alter the abnormal learned pattern of movement - "motor reprograming." Antidepressants and muscle relaxants may be also beneficial. Rarely, transcutaneous electrical stimulation applied to the area of spasm or involuntary movement may be helpful, analogous to the application of a tuning fork during clinic evaluation. Most importantly, however, the patient should try to understand what stress factors may be playing a role and seek the expertise of a psychologist experienced and skilled in stress management. The role of a psychiatrist is not to make the diagnosis but to provide insights into underlying psychological or psychiatric issues.
The severity of psychogenic movement abnormalities and prognosis varies among individuals. Long-term outcomes appear to be best in patients with a shorter duration of symptoms, those with clearly identifiable trigger or a precipitating or exacerbating factor that can be modified, and most importantly, in those patients who accept the diagnosis and work with their physicians and other healthcare professionals to help them return to the mainstream of life.
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