Psychogenic Movement Disorders Research Articles

Chapter 34 - Functional voice disorders: Clinical presentations and differential diagnosis

In this chapter, an overview of the heterogeneous group of functional voice disorders is given, including the psychogenic voice disorder (PVD) and hyperfunctional or muscle tension voice disorder (MTVD) subgroups. Reference is made to prevalence and demographic data, with empiric evidence for psychosocial factors commonly associated with the onset and maintenance of these disorders. Clinical features that distinguish between the different presentations of PVD and MTVD are described. While there are some shared characteristics, key differences between these two subgroups indicate that PVD more closely resembles the psychogenic movement disorders and a range of other functional neurologic disorders. Assessment procedures and auditory-perceptual features of the voice that distinguish these disorders from the neurologically based voice disorders are discussed, with case examples highlighting ambiguous features that may influence differential diagnosis. The clinical profiles of PVD and MTVD affirm approaches to clinical management by speech-language pathologists that integrate symptomatic behavioral voice therapy with "top-down" models of counseling or psychotherapy. They also support the proposition that PVD may be construed as a subtype of functional neurologic disorders.

Atypical presentation of psychogenic movement disorder with jaw-opening dystonia: two cases reports

Atypical presentation of psychogenic movement disorder with jaw-opening dystonia: two cases reports

Cognitive therapies for psychogenic movement disorders

Cognitive therapies for psychogenic movement disorders

Electrophysiological evaluation of psychogenic movement disorders

Psychogenic movement disorders (PMD) include a group of neurological symptoms which cannot be explained by any organic syndrome. The diagnosis of PMD is challenging for both neurologist and psychiatrist. Electrophysiological examination is a useful tool to evaluate and support a diagnosis PMD. It includes a set of tests which are chosen appropriate to the clinical setting that provides objective criteria for the diagnosis of PMD. The various tests available include accelerometry, surface electromyography, electroencephalography, jerk locked back averaging and pre-movement potentials, somatosensory evoked potentials, transcranial magnetic stimulation (TMS) etc. Electrophysiologically psychogenic tremors display features of variability, entrainability, coactivation, distractibility and increase in the amplitude and frequency on mass loading. Movement related cortical potentials such as Bereitschaftspotential is seen in psychogenic myoclonus. Presence of triphasic contraction of muscles and absence of co-contraction suggests psychogenic myoclonus. Latency of C-reflex is longer in psychogenic myoclonus as compared to organic myoclonus. The role of TMS to differentiate psychogenic from organic dystonia is still not clear. In conclusion, electrophysiological tests are most useful for tremor, followed by jerks and least for dystonia. In patients with long-standing PMD or those with mixed pathology, electrophysiological tests may not be very useful.

Functional (psychogenic) movement disorders – Clinical presentations

Functional or psychogenic movement disorders are common and disabling, and sometime difficult to diagnose. The history and physical exam can give positive features that will support the diagnosis, which should not be based solely on exclusion. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, history of other somatic symptom and secondary gain. Anxiety and depression are common, but not necessarily more than the general population. On examination, distraction and suggestibility may be present. There are specific signs that should be looked for with different types of movements. For example, with tremor, change in frequency over time and entrainment are common features. With myoclonus, the movements might be complex in type with long latencies to stimulus induced jerks. Gait disorders show good balance despite claims to the contrary. Functional dystonia still remains a challenging diagnosis in many circumstances, although fixed dystonia is one sign more likely to be functional.

Psychogenic Movement Disorders in Children

Although there has been a recent revival in interest in psychogenic disorders and psychogenic movement disorders (PMD) in particular, there are relatively few publications dealing specifically with PMD in children. This review looks at multiple aspects of PMD including the incidence, the clinical manifestations, and management.

SENSORY ATTENUATION ASSESSED BY SENSORY EVOKED POTENTIALS IN FUNCTIONAL MOVEMENT DISORDERS

ObjectiveFunctional (psychogenic) movement disorders (FMD) have features associated with voluntary movement (e.g. distractibility) but patients report movements to be out of their control. One explanation for this phenomenon is that...

Conversion disorder in childhood presenting as movement disorder with severe injuries

Conversion disorder is characterized by the presence of one or more medically unexplained neurological symptoms and signs, which can manifest in all ages including children. In such cases, a stressor or conflict either initiates or exacerbates the condition. We present here a unique case of psychogenic movement disorder which was associated with injuries and when underlying stressors were identified, symptoms resolved with psychological treatment alone.

Speech and voice disorders in patients with psychogenic movement disorders.

Psychogenic speech and voice disorders (PSVDs) may occur in isolation but more typically are encountered in the setting of other psychogenic disorders. We aimed to characterize the phenomenology, frequency, and correlates of PSVDs in a cohort of patients with psychogenic movement disorders (PMDs). We studied 182 consecutive patients with PMDs, 30 of whom (16.5 %) also exhibited PSVD. Stuttering was the most common speech abnormality (n = 16, 53.3 %), followed by speech arrests (n = 4, 13.3 %), foreign accent syndrome (n = 2, 6.6 %), hypophonia (n = 2, 6.6 %), and dysphonia (n = 2, 6.6 %). Four patients (13.2 %) had more complex presentations with different combinations of these patterns. No differences in gender, age at onset, and distribution of PMDs were observed between patients with and without PSVD. PSVDs are relatively frequent in patients with PMDs and are manifested by a wide variety of abnormal speech and voice phenomena, with stuttering being the most common presentation. Speech therapy and insight-oriented counseling may be helpful to some patients.

Sensory Attenuation Assessed by Sensory Evoked Potentials in Functional Movement Disorders.

BackgroundFunctional (psychogenic) movement disorders (FMD) have features associated with voluntary movement (e.g. distractibility) but patients report movements to be out of their control. One explanation for this phenomenon is that sense of agency for movement is impaired. The phenomenon of reduction in the intensity of sensory experience when movement is self-generated and a reduction in sensory evoked potentials (SEPs) amplitude at the onset of self-paced movement (sensory attenuation) have been linked to sense of agency for movement.MethodsWe compared amplitude of SEPs from median nerve stimulation at rest and at the onset of a self-paced movement of the thumb in 17 patients with FMD and 17 healthy controls.ResultsPatients showed lack of attenuation of SEPs at the onset of movement compared to reduction in amplitude of SEPs in controls. FMD patients had significantly different ratios of movement onset to rest SEPs than did healthy controls at each electrode: 0.79 in healthy controls and 1.35 in patients at F3 (t = -4.22, p<0.001), 0.78 in healthy controls and 1.12 at patients C3 (t = -3.15, p = 0.004) and 0.77 in healthy controls and 1.05 at patients P3 (t = -2.88, p = 0.007).ConclusionsPatients with FMD have reduced sensory attenuation as measured by SEPs at onset of self-paced movement. This finding can be plausibly linked to impairment of sense of agency for movement in these patients.

Functional (psychogenic) movement disorders associated with normal scores in psychological questionnaires: A case control study

ObjectiveFunctional movement disorders (FMDs) fall within the broader category called functional neurological symptom disorder (FNSD). New DSM-5 criteria for FNSD no longer require the presence of a ‘psychological conflict’ suggesting that some patients with FMD may not have obvious psychological comorbidity. We studied patients with FMD in comparison to patients with a neurological movement disorder (MD) and healthy controls (HC) to identify whether there is a subgroup of patients with FMD who have normal psychological test scores. MethodsWe assessed self-rated measures of depression/anxiety (SCL-90), dissociation and personality disorder (PDQ-4) in patients attending neurological clinics and healthy controls. The proportion of patients scoring within normal ranges was determined, and the levels of somatic and psychological symptoms were compared between the three groups. ResultsAmong the FMD group, 39% (20/51) scored within the normal range for all measures compared to 38% (13/34) of MD subjects and 89% (47/53) of healthy controls. There were no differences in overall scores in the SCL-90 and PDQ-4 between FMD and MD patients. FMD patients also did not differ from controls on a self-rated measure of personality pathology. ConclusionOur data show that a substantial proportion of patients with FMD score within the normal range in psychological questionnaires, lending some support to the new DSM-5 criteria.

Phenotype-specific diagnosis of functional (psychogenic) movement disorders.

Published diagnostic criteria for functional (psychogenic) movement disorders (FMDs) include psychiatric symptoms and some historical variables to affect the threshold between categories of diagnostic certainty. Clinically probable and possible categories, however, do not suffice to rule in FMD or rule out complex organic movement disorders and therefore are of little practical help. In contrast, a handful of unequivocal and reliably incongruent or inconsistent clinical features in each functional movement phenotype, when present, allow a clinically definite diagnosis of FMD, regardless of any psychiatric symptom. We suggest that the use of phenotype-specific clinically definite FMD diagnostic criteria will increase inter-rater reliability and minimize false-positive diagnostic errors. This process involves the ascertainment of core (mandatory) examination features instead of supportive but insufficiently sensitive historical, psychiatric, and inconsistent examination features.

Alexithymia in Neurological Disease: A Review.

Alexithymia has been considered a personality trait characterized by difficulties identifying and describing feelings and an externally oriented thinking style. A high rate of alexithymia is reported among patients with psychiatric and psychosomatic disorders. In this review, the authors examined the literature regarding the prevalence and importance of alexithymia in patients with neurological disorders. A systematic search of the computerized databases MEDLINE and PubMed was conducted in order to identify papers on alexithymia in neurological disease. Key search terms used included "traumatic brain injury," "head trauma," "head injury," "stroke," "epilepsy," "brain tumor," "multiple sclerosis," "Alzheimer's disease," "Parkinson's disease," "Huntington's disease," "Gilles de la Tourette syndrome," "dystonia," "psychogenic movement disorders," "functional movement disorders," "nonepileptic attacks," and "nonepileptic seizures." These search terms were paired with "alexithymia." Alexithymia seems to be a common feature of neurological disease, with most evidence available for patients with traumatic brain injury, stroke, and epilepsy. However, it is not clear how independent it is from affective disorders such as depression and anxiety, which are themselves very common in neurological conditions. Identification of alexithymia could be relevant for prognosis and therapeutic decisions in patients with neurological disease and is certainly worthy of further study. Tools with which to measure alexithymia and delineation from affective disorders and apathy are important methodological issues for future work.

Recognizing uncommon presentations of psychogenic (functional) movement disorders.

BackgroundPsychogenic or functional movement disorders (PMDs) pose a challenge in clinical diagnosis. There are several clues, including sudden onset, incongruous symptoms, distractibility, suggestibility, entrainment of symptoms, and lack of response to otherwise effective pharmacological therapies, that help identify the most common psychogenic movements such as tremor, dystonia, and myoclonus.MethodsIn this manuscript, we review the frequency, distinct clinical features, functional imaging, and neurophysiological tests that can help in the diagnosis of uncommon presentations of PMDs, such as psychogenic parkinsonism, tics, and chorea; facial, palatal, and ocular movements are also reviewed. In addition, we discuss PMDs at the extremes of age and mass psychogenic illness.ResultsPsychogenic parkinsonism (PP) is observed in less than 10% of the case series about PMDs, with a female–male ratio of roughly 1:1. Lack of amplitude decrement in repetitive movements and of cogwheel rigidity help to differentiate PP from true parkinsonism. Dopamine transporter imaging with photon emission tomography can also help in the diagnostic process. Psychogenic movements resembling tics are reported in about 5% of PMD patients. Lack of transient suppressibility of abnormal movements helps to differentiate them from organic tics. Psychogenic facial movements can present with hemifacial spasm, blepharospasm, and other movements. Some patients with essential palatal tremor have been shown to be psychogenic. Convergence ocular spasm has demonstrated a high specificity for psychogenic movements. PMDs can also present in the context of mass psychogenic illness or at the extremes of age.DiscussionClinical features and ancillary studies are helpful in the diagnosis of patients with uncommon presentations of psychogenic movement disorders.

Diagnostic performance of the "Huffing and Puffing" sign in psychogenic (functional) movement disorders.

To determine the diagnostic value of effort-associated behaviors ("huffing and puffing" spectrum) in patients with psychogenic movement disorders. Three blinded clinicians rated presence, severity, and duration of effort-associated features during standing and walking tasks on edited videos of 131 patients with psychogenic gait disorders and 37 patients with organic gait disorders. Huffing, grunting, grimacing, and breath holding were the most common effort-associated behaviors in patients with psychogenic gait disorders, with a combined prevalence of 44% and disproportionate to the severity of gait impairment compared to organic gait disorders. The presence of "huffing and puffing"-type behaviors yielded a relatively low sensitivity but high specificity for the diagnosis of psychogenic movement disorders, increasing the odds of diagnosis 13-fold (95%, CI: 4.2-43.8) compared to organic gait disorders. Demonstration of effort-associated behaviors during standing and walking strongly supports the psychogenic nature of disorders when gait is involved.

Propriospinal myoclonus: clinical reappraisal and review of literature.

Propriospinal myoclonus (PSM) is a rare disorder with repetitive, usually flexor arrhythmic brief jerks of the trunk, hips, and knees in a fixed pattern. It has a presumed generation in the spinal cord and diagnosis depends on characteristic features at polymyography. Recently, a historical paradigm shift took place as PSM has been reported to be a functional (or psychogenic) movement disorder (FMD) in most patients. This review aims to characterize the clinical features, etiology, electrophysiologic features, and treatment outcomes of PSM. Re-evaluation of all published PSM cases and systematic scoring of clinical and electrophysiologic characteristics in all published cases since 1991. Of the 179 identified patients with PSM (55% male), the mean age at onset was 43 years (range 6-88 years). FMD was diagnosed in 104 (58%) cases. In 12 cases (26% of reported secondary cases, 7% of total cases), a structural spinal cord lesion was found. Clonazepam and botulinum toxin may be effective in reducing jerks. FMD is more frequent than previously assumed. Structural lesions reported to underlie PSM are scarce. Based on our clinical experience and the reviewed literature, we recommend polymyography to assess recruitment variability combined with a Bereitschaftspotential recording in all cases.

Acute movement disorders in children: experience from a developing country.

We describe acute movement disorders in 92 children, aged 5 days to 15 years, from an Indian tertiary hospital. Eighty-nine children had hyperkinetic movement disorders, with myoclonus in 25, dystonia in 21, choreoathetosis in 19, tremors in 15, and tics in 2. Tetany and tetanus were seen in 5 and 2 children, respectively. Hypokinetic movement disorders included acute parkinsonism in 3 children. Noninflammatory and inflammatory etiology were present in 60 and 32 children, respectively. Benign neonatal sleep myoclonus in 16 and opsoclonus myoclonus syndrome in 7 accounted for the majority of myoclonus cases. Vitamin B12 deficiency in 13 infants was the most common cause of tremors. Rheumatic fever and encephalitis were the most common causes of acute choreoathetosis. Acute dystonia had metabolic etiology in 6 and encephalitis and drugs in 3 each. Psychogenic movement disorders were seen in 4 cases only, although these patients may be underreported.

Psychogenic nonepileptic seizures and psychogenic movement disorders: two sides of the same coin?

Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are commonly seen in Neurology practice and are categorized in the DSM-5 as functional neurological disorders/conversion disorders. This review encompasses historical and epidemiological data, clinical aspects, diagnostic criteria, treatment and prognosis of these rather challenging and often neglected patients. As a group they have puzzled generations of neurologists and psychiatrists and in some ways continue to do so, perhaps embodying and justifying the ultimate and necessary link between these specialties.

Transcranial Sonography and 123I-FP-CIT Single Photon Emission Computed Tomography in Movement Disorders

Diagnosis of Parkinson's disease (PD) can be difficult in the early stages of the disease. The aim of the study described here was to assess the correlation between transcranial sonography (TCS) and 123I-FP-CIT ([123I]ioflupane, N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-[123I]iodophenyl)nortropane) SPECT (single photon emission computed tomography) findings and the diagnosis of PD. A total of 49 patients were enrolled in the study: 29 patients with PD, 7 patients with other parkinsonian syndromes, 11 patients with essential tremor and 2 with psychogenic movement disorder. Substantia nigra echogenicity was measured using TCS. SPECT was performed using DaTSCAN ([123I]ioflupane). TCS and SPECT findings were correlated in 84% of patients, with κ = 0.62 (95% confidence interval: 0.38–0.86). TCS-measured substantia nigra echogenicity and SPECT-measured striatal binding ratio were negatively correlated (r = –0.326, p = 0.003). TCS/SPECT sensitivity, specificity and positive and negative predictive values for the diagnosis of PD were 89.7%/96.6%, 60.0%/70.0%, 76.5%/82.4% and 80.0%/93.3%, respectively. Both positive TCS and SPECT findings correlated significantly with the diagnosis of PD (κ = 0.52, 95% confidence interval: 0.27–0.76, and κ = 0.69, 95% confidence interval: 0.49–0.90, respectively).

Psychogenic tremor: a video guide to its distinguishing features.

BackgroundPsychogenic tremor is the most common psychogenic movement disorder. It has characteristic clinical features that can help distinguish it from other tremor disorders. There is no diagnostic gold standard and the diagnosis is based primarily on clinical history and examination. Despite proposed diagnostic criteria, the diagnosis of psychogenic tremor can be challenging. While there are numerous studies evaluating psychogenic tremor in the literature, there are no publications that provide a video/visual guide that demonstrate the clinical characteristics of psychogenic tremor. Educating clinicians about psychogenic tremor will hopefully lead to earlier diagnosis and treatment.MethodsWe selected videos from the database at the Parkinson’s Disease Center and Movement Disorders Clinic at Baylor College of Medicine that illustrate classic findings supporting the diagnosis of psychogenic tremor.ResultsWe include 10 clinical vignettes with accompanying videos that highlight characteristic clinical signs of psychogenic tremor including distractibility, variability, entrainability, suggestibility, and coherence.DiscussionPsychogenic tremor should be considered in the differential diagnosis of patients presenting with tremor, particularly if it is of abrupt onset, intermittent, variable and not congruous with organic tremor. The diagnosis of psychogenic tremor, however, should not be simply based on exclusion of organic tremor, such as essential, parkinsonian, or cerebellar tremor, but on positive criteria demonstrating characteristic features. Early recognition and management are critical for good long-term outcome.