Psychogenic (functional) movement disorders

Jose Fidel Baizabal-Carvallo MD (Dr. Baizabal-Carvallo of Baylor College of Medicine has no relevant financial relationships to disclose.)
Joseph Jankovic MD, editor. (Dr. Jankovic, Director of the Parkinson's Disease Center and Movement Disorders Clinic at Baylor College of Medicine, received research funding from Allergan, Allon, Ceregene, Chelsea, EMD Serono, Impax, Ipsen, Lundbeck, Medtronic, Merz, and Teva, and compensation for his services as a consultant or an advisory committee member by Allergan, Auspex, EMD Serono, Lundbeck, Merz, Neurocrine Biosciences, and Teva.)
Originally released September 29, 1994; last updated November 21, 2016; expires November 21, 2019

This article includes discussion of psychogenic (functional) movement disorders, psychogenic movement disorders, Briquet syndrome, conversion symptom, functional movement disorders, psychogenic myoclonus, psychogenic tremor, pseudo-tics, psychogenic parkinsonism, and psychogenic gait disorders. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Psychogenic movement disorders represent a challenge for the clinical practitioner, as the diagnosis and treatment are usually difficult and the prognosis may be poor in some patients. Sometimes also referred to as “functional,” “conversion,” or “psychogenic,” these disorders must be differentiated from “organic” disorders. Psychogenic movement disorders may have several presentations, including tremor, dystonia, myoclonus, tics, parkinsonism, gait disorders, hemifacial spasm, opsoclonus, oculogyric crisis, painful legs, moving toes, etc. and are not uncommonly accompanied by psychogenic speech and voice disorders. In this article, the author discusses current advances in the diagnosis, pathophysiology, and treatment of psychogenic movement disorders.

Key points

 

• There is currently a lively debate whether the term psychogenic or functional should be used to describe these movements, with both terms having advantages and disadvantages.

 

• Psychogenic movement disorders may have a wide variety of presentation; although tremor, dystonia, myoclonus, and gait disorders are among the most common, tics, parkinsonism, abnormal ocular movements, palatal tremor, and hemifacial spasm can also be observed.

 

• The diagnosis of psychogenic movement disorders should be based on positive clinical findings rather than being a diagnosis of exclusion.

 

• The prognosis of psychogenic movement disorders is usually poor; however, a short duration of the symptoms with an acceptable explanation and understanding of the disorder by the patient are considered important good prognostic factors.

 

• Current advances in the use of functional brain imaging are providing further information about the pathogenesis of these conditions.

Historical note and terminology

The French school headed by Charcot directed attention to hysteria and its neurologic consequences in the second half of the 19th century. Hysteria has been an umbrella concept for the type of psychogenic impairment associated with movement disorders; it has been emphasized that among patients with “hysterical symptoms,” 80% do not have a hysterical personality, which makes the term imprecise as a diagnostic category (Marsden 1986; Marsden 1995). Charcot believed that prompt treatment of hysterical symptoms was important for good outcome and encouraged induction of second attacks using “hysterogenic points” or hypnosis for the diagnosis and treatment of many neurologic complaints. Charcot believed that dystonic posturing or contractures were most commonly seen in hysterics. In 1 such case, Charcot treated a young woman suffering with what we now would call psychogenic foot dystonia by inducing an attack 4 days after onset resulting in complete resolution of symptoms (Charcot 1987). Many criticized this approach to treatment, as it would lead to imitations and behavior reinforcement. The English school headed by Gowers and Henry Head was critical on this point. Gowers observed that neurotics might suffer from many symptoms including spasm, palsy, and coma. He emphasized that there were few organic brain diseases not “imitated” by neurosis and the clinician must exclude any potential organic cause for the symptoms before concluding that they are psychogenic in origin (Gowers 1888; Head 1992).

Charcot and his followers used hypnosis as a powerful tool for demonstrating how, on occasion, subconscious motivations could generate a variety of disabilities resembling those seen in the context of bona fide neurologic disease (Guillain 1959; Freud 1957). Charcot proposed that hysteria was congenitally derived, and that lesions responsible for this condition might ultimately be found somewhere in the brain. At that time, Janet emphasized the concept that “fixed ideas” could act in an unconscious level, and such unconscious mind may “dissociate” from the conscious mind under certain circumstances such as hypnosis or emotional states (Spiegel et al 2011). Following the same line of thought, the term “hysteria” was replaced by “conversion” disorders, under the influence of Sigmund Freud who proposed that these symptoms result from a transformation (or conversion) of a psychological conflict into a symbolic physical manifestation because of repression of the unconscious mind, related to sexual conflicts. By the end of the 19th century Joseph Babinski, a Charcot's student, aimed to identify clinical signs that distinguish “conversion” from organic disorders. He introduced the term “pithiathism” (from the Greek “persuasion”) following the observation that suggestion is characteristic in these patients (Vuilleumier 2014). Conversion disorders have been classified under the somatoform disorders (Briquet syndrome), a group of longstanding poly-symptomatic manifestations without evidence of an organic origin. Currently, the term "psychogenic" is used to describe abnormal movements believed to derive from an underlying psychological or psychiatric disorder (Hallett et al 2011). However, a substantial proportion of patients with a movement disorder labeled "psychogenic" does not always fit into an established psychiatric diagnosis (such as personality disorders, neurotic tendencies, or psychotic states), puzzling clinicians because of their apparent lack of appropriate characteristic psychosocial features or evidence for secondary gain (Putnam 1992). For these reasons some authors have proposed the term “functional movement disorders” (Edwards et al 2014); however, this term may also be misleading in part because these disorders are dysfunctional rather than functional (Jankovic 2014). Furthermore, the term “functional” is not easily understood by patients, lacks scientific specificity, can be a disservice, and may delay treatment; but more importantly, the term psychogenic could be a tactful way to lead the patient to acceptance of the diagnosis and to provide proper therapy (Fahn and Olanow 2014; Jankovic 2014). In this review, we will use the term “psychogenic” rather than “functional,” but both terms are currently used in modern literature.

The DSM-5 (American Psychiatric Association 2013) classification of psychiatric disorders includes additional categories under which a psychogenic movement disorder might reside, such as somatic symptom disorder, conversion disorder, illness anxiety disorder, and factitious disorders. In a minority of cases, the primary psychiatric disorders are factitious disorders or malingering, in which the abnormal movements are feigned (Batshaw et al 1985; American Academy of Neurology 2006). However, the term “malingering,” has been removed from DSM-5 as it is thought to represent a voluntary condition rather than a mental illness.

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