This article discusses the various types of psychogenic movement disorders, clinical pointers towards their diagnosis and effective treatment strategies.
Movements are categorized into four classes:
Automatic movements are learned motor acts that are performed without conscious effort. For example: opening the door while entering a room, tapping one's fingers while thinking about something.
Voluntary movements are planned or self-initiated. In other words, the movements are intentional and are externally triggered. For example: withdrawing the hand from a hot plate.
Semi voluntary Movements:
Semi-voluntary movements are induced by an inner stimulus that is sensory in nature. For example, a need to scratch an itch.
An important difference between semi-voluntary and involuntary movements is that the patient can suppress semi-voluntary movements, and involuntary movements are often non-suppressible or partially suppressible (some tremors, chorea, dystonia, stereotypies, and some tics).
Movement disorders are classified into two types:
Hypokinetic disorders: Parkinsonism is a common example of hypokinetic movement disorder. Hypokinesia refers to slowness of movement, a cardinal feature of Parkinsonism, along with resting tremor and rigidity (increased muscle tone).
Hyperkinetic disorders: Examples of hyperkinetic movement disorders include dystonias, Huntington disease, chorea, ballism, athetosis, Tourette syndrome, myoclonus, ataxia, restless legs syndrome, or Willis-Ekbom disease, and Psychogenic Movement Disorder.
These are an often neglected category of movement disorders. Psychological factors cause these, and hence they were earlier classified as functional or non-organic movement disorders. Earlier, they fell under the category of medically unexplained symptoms, and in that, a diagnosis was made only after other organic causes were ruled out. One must not assume that the term "functional" always points to a psychogenic basis. In the past, the term "functional" has been used to denote organic diseases in which a specific cause was not determined. However, much debate continues regarding these terminologies in the international forum for movement disorders.
In the recent past, there has been an upward trend in the occurrence of psychogenic movement disorders, and studies estimate that their global prevalence is around 1 to 9 % in all neurologic diagnoses. To be classified as a psychogenic movement disorder, no organic cause should be evident, and there should be an overlay of a psychiatric disorder. Therefore, it is imperative to explore psychodynamics, which could point to the etiology in such cases.
It is intellectually intriguing that the human brain is capable of creating neuro deficits such as paralysis, sensory loss, blindness, epilepsy from physiologic factors. However, no investigation exists that can differentiate between an involuntary and a voluntary movement disorder.
First of all, patients should understand that they have a movement disorder, such as tremor or dystonia.
The disorder is not because of any damage to the brain, nerves, or spinal cord. Still, it is a manifestation of how their bodies respond to stress.
Just as stress causes an elevation in blood pressure, palpitations, and tremors, it can manifest as movement disorders.
Naturally, the diagnosis of stress-induced psychogenic movement disorder can be a delicate matter for both physicians and patients.
Patients manifesting movements or other motor abnormalities will not readily recognize or acknowledge that they are stress-induced and may disagree with the diagnosis.
And physicians believe that it is in the patient's best interest to be honest, candidly disclose the diagnosis, and discuss the psychological nature of the movement disorder.
Not all patients will accept the diagnosis.
In many cases, it takes more time, or even several visits, before the patient begins to understand the relationship between stress, underlying psychiatric and psychological conditions, and the movement disorder.
A diagnosis can only be made by:
Meticulous history taking.
Specifically looking for stressors before the episode onset.
By observing the patient during an attack.
The pejorative term Hysterical Conversion Disorder is no longer in use as it was found to be derogatory.
In addition to that, modern-day brain imaging techniques have found an "organic" basis even for psychogenic movement disorders as a dysfunction involving the thalamus, basal ganglia, and striato-thalamo-cortical circuits.
Some pointers towards the diagnosis of psychogenic movement disorders include abrupt onset, inconsistent and incongruous movements, bizarre gait, excessive fatigue, excessive startle response to a stimulus, spontaneous remissions, the disappearance of movements with distraction, response to placebo treatment and strong suggestions, deliberate slowness of movement and multiple vague somatizations.
Psychiatric conditions that often masquerade as psychogenic movement disorders include somatoform disorder, factitious disorder, malingering, depression, and anxiety disorder.
In addition, these may take the form of psychogenic tremor, psychogenic gait, psychogenic dystonia, psychogenic tics, psychogenic myoclonus, and surprisingly even psychogenic Parkinsonism.
The diagnosis is also based on a combination of several clinical observations and recognition of typical characteristics that include:
The onset of the movements is sudden or abrupt.
Movements triggered by emotional or physical trauma or conflict like marital, sexual, or work-related.
Movements are episodic or intermittent.
Spontaneous releases of the movements.
Movements cease with distraction.
Underlying psychiatric disturbances like depression or anxiety are present.
Lack of emotional concern about the disorder.
Exposure to neurologic disorders during the occupation (for example, nurse, physician) or taking care of someone with similar problems.
Other characteristics include:
Slurred speech, gibberish, soft voice, or foreign accent.
Active resistance against passive movement.
A blood test or any other diagnostic test cannot be done for psychogenic movement disorder. The diagnosis of a psychogenic movement disorder is a two-step process. The first step is to make a positive diagnosis that the movements are psychogenic rather than from an organic illness. The second step is to identify either a psychiatric disorder, such as depression or anxiety, or the psychodynamics that could explain the abnormal movements. It is essential to properly diagnose psychogenic movement disorder because only then can we give appropriate treatment.
Additionally, suppose the patient has been misdiagnosed with a psychogenic movement disorder. In that case, the patient may be given inappropriate treatment, such as inappropriate medication that may create harmful side effects. This will also postpone appropriate psychiatric treatment. Delaying or improper diagnosis and treatment may lead to chronic disability.
Correct diagnosis is of vital importance. Suppose clinicians fail to identify psychogenic movement disorders. In that case, the patient can be put unnecessarily on medications that will have debilitating side effects, like cognitive impairment, excessive dryness of the mouth, drying up of the tears, constipation, blurred vision, and difficulty in urination.
Always communicate with a psychiatrist for effective and appropriate management of these disorders. A psychiatrist can only make the diagnosis, and the diagnosis dictates further management. Wrong diagnoses can have deleterious consequences.
Evidence-based treatment approaches include:
Cognitive Behavioral Therapy (CBT).
Placebo therapy utilizing strong suggestions.
Usage of antidepressants if necessary after evaluation of the mental state of the patient.
Brain stimulation techniques in treatment-resistant cases.
Psychogenic movement disorders are common, but diagnosing may be difficult. Visual appearance alone is usually insufficient to make a proper diagnosis, but such information is undoubtedly important. The severity of psychogenic movement abnormalities and prognosis varies among individuals. Long-term outcomes appear to be best in patients with a shorter span of symptoms. Most importantly, the patients who accept the diagnosis and work with their physicians and other healthcare professionals will help them return to their mainstream of life.
Last reviewed at:
06 Jul 2021 - 5 min read
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