Impact of psychogenic movement disorders versus Parkinson's on disability, quality of life, and psychopathology

Functional (psychogenic) gait disorder: diagnosis and management

Functional (psychogenic) gait disorders are a common presentation of functional neurological disorder - one of the commonest diagnoses made in neurology practice. People with functional neurological disorder are as disabled and experience as poor a quality of life as patients with multiple sclerosis and Parkinson's disease. People with functional neurological disorder, including gait disorder, are often perceived as being challenging to diagnose and manage, and as a result attitudes of health professionals towards them are often negative. However, a rapid positive diagnosis of functional gait disorder can often be made, and with a specific approach to diagnostic explanation and treatment, many patients experience improvement in symptoms and disability, with such improvements sustained in the long term. Here I review current evidence regarding the diagnosis, pathophysiology and management of functional gait disturbance with an emphasis on how to make a positive diagnosis and how to select the most appropriate treatment approach. Rehabilitative treatments, with an emphasis on specific physiotherapy interventions, have increasing evidence for benefit, particularly if carried out following a comprehensive explanation of the diagnosis.

Corticolimbic structural alterations linked to health status and trait anxiety in functional neurological disorder

OBJECTIVE

Affective symptoms influence health status (health-related quality of life) in functional neurological disorder (FND), and the salience network is implicated in the pathophysiology of FND and mood/anxiety disorders. We hypothesised that self-reported health status and affective symptoms would map onto salience network regions and that patients with FND would show decreased insular volumes compared with controls.

METHODS

This voxel-based morphometry study investigated volumetric differences in 26 patients with FND (21 women, 5 men; mean age=40.3±11.5) compared with 27 healthy controls (22 women, 5 men; mean age=40.5±10.8). Post hoc analyses stratified patients with FND by mental and physical health scores (Short Form Health Survey-36). Within-group analyses investigated associations with mental health, physical health, trait anxiety and depression in patients with FND.

RESULTS

There were no volumetric differences between the complete FND cohort and controls. In stratified analyses, however, patients with FND reporting the most severe physical health impairments showed reduced left anterior insular volume compared with controls. In within-group analyses, impaired mental health and elevated trait anxiety were associated with increased right amygdalar volumes in patients with FND. The relationship between amygdalar volume and mental health, driven by emotional well-being deficits and role limitations due to emotional problems, was independent of sensorimotor functional neurological symptom severity and motor FND subtype. In secondary within-group analyses, increased periaqueductal grey volume was associated with role limitations due to emotional problems. Impaired physical functioning correlated with decreased left anterior insular volumes.

CONCLUSIONS

These findings support roles for several regions of the salience network in the pathophysiology of FND.

Impaired awareness of motor intention in functional neurological disorder: implications for voluntary and functional movement

BACKGROUND

Functional neurological disorders (FNDs), also known as conversion disorder, are unexplained neurological symptoms unrelated to a neurological cause. The disorder is common, yet poorly understood. The symptoms are experienced as involuntary but have similarities to voluntary processes. Here we studied intention awareness in FND.

METHOD

A total of 26 FND patients and 25 healthy volunteers participated in this functional magnetic resonance study using Libet's clock.

RESULTS

FND is characterized by delayed awareness of the intention to move relative to the movement itself. The reporting of intention was more precise, suggesting that these findings are reliable and unrelated to non-specific attentional deficits. That these findings were more prominent with aberrant positive functional movement symptoms rather than negative symptoms may be relevant to impairments in timing for an inhibitory veto process. Attention towards intention relative to movement was associated with lower right inferior parietal cortex activity in FND, a region early in the processing of intention. During rest, aberrant functional connectivity was observed with the right inferior parietal cortex and other motor intention regions.

CONCLUSIONS

The results converge with observations of low inferior parietal activity comparing involuntary with voluntary movement in FND, emphasizing core deficiencies in intention. Heightened precision of this impaired intention is consistent with Bayesian theories of impaired top-down priors that might influence the sense of involuntariness. A primary impairment in voluntary motor intention at an early processing stage might explain clinical observations of slowed effortful voluntary movement, heightened self-directed attention and underlie functional movements. These findings further suggest novel therapeutic targets.

Disentangling Stigma from Functional Neurological Disorders: Conference Report and Roadmap for the Future

A multidisciplinary expert review of key issues and future directions from the conference “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms.”

On October 9 and 10, 2015, a conference entitled “Controversial labels and clinical uncertainties: psychogenic disorders, conversion disorder, and functional symptoms” was held at the Center for Ethics, Emory University, Atlanta, GA, USA. This conference brought together a select group of 30 distinguished thought leaders and practitioners, including ethicists, researchers, clinicians, humanities scholars, and advocates to discuss the unique challenges and controversies related to the diagnosis, treatment, and stigma for patients with what is currently recognized as functional (“psychogenic”) neurological disorders. Our group of experts explored the conflicts and ethical tensions within health care that must be addressed in order to advance care for these disorders. What follows is a reflection on the conversations between conference attendees outlining key challenges and value conflicts in the diagnosis and treatment of patients with functional disorders. With this report, we aim to provide a roadmap for reducing stigma and improving care for functional neurological disorders (FND). A path forward would involve (1) setting a multifactorial research agenda that equally prioritized access to effective psychotherapy as well as identification of novel biomarkers; (2) empowering patients with FND to be heard and to drive changes in care; and (3) reducing isolation for clinicians by providing formal training and setting up multidisciplinary care teams and support networks.

5-HT2A Agonists: A Novel Therapy for Functional Neurological Disorders?

Functional neurological disorders are frequently encountered in clinical practice. They have a poor prognosis and treatment options are limited. Their etiology is unknown, but leading theories propose a disturbance of somatic self-representation: the mind perceives dysfunction of a body region despite intact motor and sensory pathways. Central to this model is the concept of an abnormal top-down cognitive influence upon sensorimotor function. There is growing interest in the use of 5-HT2A agonists in the management of neuropsychiatric conditions. Recent studies have shown that these agents induce changes in neural activity that disrupt hierarchical brain dynamics and modulate networks subserving self-related processing. Converging evidence suggests they may hold unique therapeutic potential in functional neurological disorders. This is of importance given the considerable personal and societal burden of this condition and we argue a clinical trial to test this hypothesis is warranted.

Insights into Chronic Functional Movement Disorders: The Value of Qualitative Psychiatric Interviews

BACKGROUND

Patients with functional movement disorders (FMDs) are commonly seen by neurologists and psychosomatic medicine psychiatrists. Research literature provides scant information about the subjective experiences of individuals with this often chronic problem.

OBJECTIVE

To enhance our understanding of psychologic aspects of FMDs by conducting qualitative interviews of research subjects.

METHODS

In total, 36 patients with FMDs were recruited from the Human Motor Control clinic at the National Institutes of Health. Each subject participated in a qualitative psychiatric interview and a structured diagnostic psychiatric interview.

RESULTS

Of our 36 subjects, 28 had current or lifetime psychiatric disorders in addition to conversion disorder and 22 had current disorders. Qualitative interviews provided rich information on patients' understanding of their illnesses and impaired cognitive processing of emotions.

CONCLUSION

Our study supports the addition of open-ended qualitative interviews to delineate emotional dynamics and conceptual frameworks among such patients. Exploratory interviews generate enhanced understanding of such complex patients, above and beyond that gained by assessing DSM diagnostic comorbidities.

Psychogenic Explanations of Physical Illness

In some patients with chronic physical complaints, detailed examination fails to reveal a well-recognized underlying disease process. In this situation, the physician may suspect a psychological cause. In this review, we critically evaluated the evidence for this causal claim, focusing on complaints presenting as neurological disorders. There were four main conclusions. First, patients with these complaints frequently exhibit psychopathology but not consistently more often than patients with a comparable “organic” diagnosis, so a causal role cannot be inferred. Second, these patients report a high incidence of adverse life experiences, but again, there is insufficient evidence to indicate a causal role for any particular type of experience. Third, although psychogenic illnesses are believed to be more responsive to psychological interventions than comparable “organic” illnesses, there is currently no evidence to support this claim. Finally, recent evidence suggests that biological and physical factors play a much greater causal role in these illnesses than previously believed. We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In future research, researchers need to take a wider view concerning the etiology of these illnesses.

Impaired resting vagal tone in patients with functional movement disorders

INTRODUCTION

The autonomic nervous system plays an integral role in the maintenance of homeostasis during times of stress. The functioning of the autonomic nervous system in patients with functional movement disorders (FMD) is of particular interest given the hypothesis that converted psychological stress plays a critical role in FMD disease pathogenesis. We sought to investigate autonomic nervous system activity in FMD patients by examining heart rate variability (HRV), a quantitative marker of autonomic function.

METHODS

35 clinically definite FMD patients and 38 age- and sex-matched healthy controls were hospitalized overnight for continuous electrocardiogram recording. Standard time and frequency domain measures of HRV were calculated in the awake and asleep stages. All participants underwent a thorough neuropsychological battery, including the Hamilton Anxiety and Depression scales and the Beck Depression Inventory.

RESULTS

Compared to controls, patients with FMD exhibited decreased root mean square of successive differences between adjacent NN intervals (RMSSD) (p = 0.02), a marker of parasympathetic activity, as well as increased mean heart rate (p = 0.03). These measures did not correlate with the depression and anxiety scores included in our assessment as potential covariates.

CONCLUSION

In this exploratory study, patients with FMD showed evidence of impaired resting state vagal tone, as demonstrated by reduced RMSSD. This decreased vagal tone may reflect increased stress vulnerability in patients with FMD.

Are Patients with Psychogenic Movement Disorders More Likely to be Healthcare Workers?

Background

Reported risk factors for the development of a psychogenic movement disorder (PMD) include young age, female gender, history of abuse, current or past psychiatric disorder, lower levels of education and socioeconomic status, and employment as a healthcare worker. Although employment in healthcare is included in several diagnostic criteria for PMD, as well as in many case series, this association has never been validated.

Methods

Using the University of Maryland Movement Disorder Database (UMMDD), we identified PMD cases, as well as patients with isolated focal dystonia as controls. An experienced movement disorder specialist diagnosed all patients, and all cases met criteria for clinically established PMD. Demographic and occupational histories were obtained from medical records and were supplemented by telephone interviews. PMD cases and controls were compared using t tests/χ² tests.

Results

Controls (n = 148) were older than PMD cases (n = 132), with an average age of 61.4 and 52.1 years, respectively (P < 0.001); there were no significant differences between groups with respect to gender, education level, and ethnicity. The proportion of healthcare workers was not significantly different between PMD cases and controls (25% of PMD cases vs. 20% of controls; P = 0.28).

Conclusions

In contrast to traditional teaching, this investigation demonstrates that in our patient population, patients with a PMD were no more likely to be employed as healthcare workers than patients with isolated focal dystonia. This study calls into question the use of employment in healthcare as a reliable criterion to support the diagnosis of PMD.

Epidemiology

The epidemiology of functional neurologic disorders (FND) is complex and has been hampered over the years by a lack of clear definition, with previous definitions struggling with an uneasy mix of both physical and psychologic components. The recent changes in DSM-5 to a definition based on positive identification of physical symptoms which are incongruent and inconsistent with neurologic disease and the lack of need for any associated psychopathology represent a significant step forward in clarifying the disorder. On this basis, FND account for approximately 6% of neurology outpatient contacts and putative community incidence rates of 4-12 per 100 000 per annum. Comorbid neurologic disease occurs in around 10% of cases. The diagnosis is reliable, with revision rates less than 5%. Of note, this revision rate was consistent prior to the widespread utilization of computed tomography and magnetic resonance imaging. FND symptoms are disabling and associated with significant distress. They are more common in women and have a peak incidence between the ages of 35 and 50; however the presentation is common in men and throughout the lifespan. The issues surrounding case definition, ascertainment, misdiagnosis, and risk factors are discussed in detail.

Psychogenic (functional) parkinsonism

Psychogenic parkinsonism (PP), although often quite disabling, is one of the least commonly reported subtypes of psychogenic movement disorders. There are certain features that help distinguish PP from idiopathic Parkinson's disease, such as abrupt onset, early disability, bilateral shaking and slowness, nondecremental slowness when performing repetitive movements, voluntary resistance against passive movement without cogwheel rigidity, distractibility, "give-way" weakness, stuttering speech, bizarre gait, and a variety of behavioral symptoms. While the diagnosis of PP is clinical, functional imaging evaluating the integrity of nigrostriatal pathways can help distinguish PP from other types of parkinsonism. PP can coexist in patients with organic parkinsonism, adding to the challenge of making a diagnosis of PP. Being cognizant of the clinical signs of psychogenic movement disorders, including PP, will lead to earlier diagnosis and hopefully improved outcomes.

Functional jerks, tics, and paroxysmal movement disorders

Functional jerks are among the most common functional movement disorders. The diagnosis of functional jerks is mainly based on neurologic examination revealing specific positive clinical signs. Differentiation from other jerky movements, such as tics, organic myoclonus, and primary paroxysmal dyskinesias, can be difficult. In support of a functional jerk are: acute onset in adulthood, precipitation by a physical event, variable, complex, and inconsistent phenomenology, suggestibility, distractibility, entrainment and a Bereitschaftspotential preceding the movement. Although functional jerks and tics share many similarities, characteristics differentiating tics from functional jerks are: urge preceding the tic, childhood onset, rostrocaudal development of the symptoms, a positive family history of tics, attention-deficit hyperactivity disorder or obsessive-compulsive symptoms, and response to dopamine antagonist medication. To differentiate functional jerks from organic myoclonus, localization of the movements can give direction. Further features in support of organic myoclonus include: insidious onset, simple and consistent phenomenology, and response to benzodiazepines or antiepileptic medication. Primary paroxysmal dyskinesias and functional jerks share a paroxysmal nature. Leading in the differentiation between the two are: a positive family history, in combination with video recordings revealing a consistent symptom pattern in primary paroxysmal dyskinesias. In this chapter functional jerks and their differential diagnoses will be discussed in terms of epidemiology, symptom characteristics, disease course, psychopathology, and supportive neurophysiologic tests.

Posttraumatic functional movement disorders

Traumatic injury to the nervous system may account for a range of neurologic symptoms. Trauma location and severity are important determinants of the resulting symptoms. In severe head injury with structural brain abnormalities, the occurrence of trauma-induced movement disorders, most commonly hyperkinesias such as tremor and dystonia, is well recognized and its diagnosis straightforward. However, the association of minor traumatic events, which do not lead to significant persistent structural brain damage, with the onset of movement disorders is more contentious. The lack of clear clinical-neuroanatomic (or symptom lesion) correlations in these cases, the variable timing between traumatic event and symptom onset, but also the presence of unusual clinical features in a number of such patients, which overlap with signs encountered in patients with functional neurologic disorders, contribute to this controversy. The purpose of this chapter is to provide an overview of the movement disorders, most notably dystonia, that have been associated with peripheral trauma and focus on their unusual characteristics, as well as their overlap with functional neurologic disorders. We will then provide details on pathophysiologic views that relate minor peripheral injuries to the development of movement disorders and compare them to knowledge from primary organic and functional movement disorders. Finally, we will comment on the appropriate management of these disorders.

Functional dystonia

Although currently lacking a sensitive and specific electrophysiologic battery test, functional (psychogenic) dystonia can sometimes be diagnosed with clinically definite certainty using available criteria. Certain regional phenotypes have been recognized as distinctive, such as unilateral lip and jaw deviation, laterocollis with ipsilateral shoulder elevation and contralateral shoulder depression, fixed wrist and finger flexion with relative sparing of the thumb and index fingers, and fixed foot plantar flexion and inversion. The pathophysiologic abnormalities in functional dystonia overlap substantially with those of organic dystonia, with similar impairments in cortical and spinal inhibition and somatosensory processing, but with emerging data suggesting abnormalities in regional blood flow and activation patterns on positron emission tomography and functional magnetic resonance imaging, respectively. Management of functional dystonia begins with compassionate and assertive debriefing of the diagnosis to ensure full acceptance by the patient, a critical step in enhancing the likelihood of success with physical rehabilitation, and psychodynamic or cognitive therapy. Physical therapy, with or without cognitive behavioral therapy, appears to be of benefit but has not yet been examined in a controlled fashion. While the prognosis remains grim for a substantial majority of patients, partly stemming from restricted mobility, delayed diagnosis, and inappropriate pharmacotherapy, early recognition and initiation of therapy stand to minimize iatrogenic harm and unnecessary laboratory investigations, and potentially reduce the long-term neurologic disability.

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.

Functional limitations in functional somatic syndromes and well-defined medical diseases. Results from the general population cohort LifeLines

OBJECTIVE

Functional somatic syndromes (FSS), defined as physical syndromes without known underlying organic pathology, are sometimes regarded as less serious conditions than well-defined medical diseases (MD). The aims of this study were to evaluate functional limitations in FSS, and to compare the results to MD patients with the same core symptoms.

METHODS

This study was performed in 89,585 participants (age: 44.4±12.4 years, 58.5% female) of the general-population cohort LifeLines. Quality of Life (QoL) and work participation were examined as indicators of functional limitations. QoL was assessed with two summary scales of the RAND-36: the physical component summary (PCS) and the mental component summary (MCS). Work participation was assessed with a self-reported questionnaire. QoL and work participation were compared between FSS and MD patients, using Chi-squared tests and ANCOVA-analyses, adjusted for age, sex, educational level, and mental disorders.

RESULTS

Of the participants, 11.0% (n=9861) reported a FSS, and 2.7% (n=2395) reported a MD. Total QoL, PCS and MCS were significantly lower in all separate FSS and MD compared to controls (P≤.001). Clinically relevant differences in QoL were found between chronic fatigue syndrome and multiple sclerosis patients, and between fibromyalgia syndrome and rheumatoid arthritis patients. Compared to controls, FSS and MD patients reported a comparably reduced working percentage, increased sick absence, early retirement due to health-related reasons, and disability percentage (P≤.001).

CONCLUSION

Functional limitations in FSS patients are common, and as severe as those in patients with MD when looking at QoL and work participation, emphasizing that FSS are serious health conditions.

An update on functional (psychogenic) tremor

Functional tremor accounts for at least 50% of patients with functional movement disorders. The diagnostic work-up of these patients can be challenging. It is a multistep process based on patients’ history and clinical criteria finally providing a ‘positive’ diagnosis. Variability of the tremor over the disease course and during clinical examination is characteristic. Patients often show increased attention toward the tremulous body part and distractability of the tremor once attention is drawn away. Sometimes distractability becomes obvious during history taking or neurological examination, in others certain distraction tasks are needed. If uncertainty remains, ancillary investigations such as electrophysiological tests may be helpful. Recent studies suggested that a loss of sense of control of ones actions may help to explain why patients with functional tremor report that they do not experience the abnormal movement as voluntary. Treatment has to be placed in a multidisciplinary team involving neurologists, psychiatrists, physiotherapists and psychologists.

Psychogenic movement disorders

PURPOSE OF REVIEW

This review describes the main clinical features of psychogenic (functional) movement disorders and reports recent advances in diagnosis, pathophysiology, and treatment.

RECENT FINDINGS

The terminology and definition of patients with psychogenic movement disorders remain subjects of controversy; the term "functional" has been used more frequently in the literature in recent years regarding the neurobiological substrate underpinning these disorders. Correct diagnosis of psychogenic movement disorders should rely not on the exclusion of organic disorders or the sole presence of psychological factors but on the observation or elicitation of clinical features related to the specific movement disorder (ie, a positive or inclusionary rather than exclusionary diagnosis). Sudden onset, spontaneous remissions, and variability over time or during clinical examination are useful "red flags" suggestive of a psychogenic movement disorder. Imaging studies have demonstrated impaired connectivity between limbic and motor areas involved in movement programming and hypoactivity of a brain region that compares expected data with actual sensory data occurring during voluntary movement. Treatment of psychogenic movement disorders begins with ensuring the patient's acceptance of the diagnosis during the initial debriefing and includes nonpharmacologic (cognitive-behavioral therapy, physiotherapy) and pharmacologic options.

SUMMARY

Psychogenic movement disorders represent a challenging disorder for neurologists to diagnose and treat. Recent advances have increased understanding of the neurobiological mechanism of psychogenic movement disorders. Treatment with cognitive strategies and physical rehabilitation can benefit some patients. As short duration of disease correlates with better prognosis, early diagnosis and initiation of treatment are critical.

Large-field repetitive transcranial magnetic stimulation with circular coil in the treatment of functional neurological symptoms

OBJECTIVE

Patients with functional neurological symptoms (FNS) are frequently encountered by neurologists and are difficult to treat. Symptoms are multiple and may appear concurrently or successively in the same patient. To date, few studies have been published on focal repetitive transcranial magnetic stimulation (rTMS) in FNS. This type of stimulation induces a focal current, vertically in the cortex. Results are contradictory, probably because it is difficult to identify a limited cortical area that triggers these symptoms. We assessed the efficacy of another type of rTMS: large-field stimulation by means of a circular coil covering a surface area approximately 20 times greater and inducing a circular current tangentially to the cortex.

PUBLISHED STUDIES

We analysed two studies on the efficacy of large-field rTMS in functional paralysis and in functional movement disorders. The efficacy of large-field rTMS was very marked in these two studies.

PERSONAL NON-PUBLISHED STUDIES

We reported several open series, including patients with functional sensory loss, functional visual loss, and non-epileptic seizures.

METHOD

For all patients, one or several sessions of 60 stimuli with circular coil were carried out with a protocol depending on the symptoms.

RESULTS

The efficacy of large-field rTMS was dramatic in all patient series. Additionally, we discuss the possible involved mechanism: placebo effect, cognitive behavioural effect or neuromodulatory effect.

CONCLUSION

According to the data from these different studies, large-field rTMS could be a new therapy for patients with FNS. However, controlled studies are mandatory.

The prognosis of functional (psychogenic) motor symptoms: a systematic review

BACKGROUND

The prognosis of functional (or psychogenic) motor symptoms (weakness and movement disorder) has not been systematically reviewed.

METHODS

We systematically reviewed PubMed for all studies of eight or more patients with functional motor symptoms reporting follow-up data longer than 6 months (excluding studies reporting specific treatments). We recorded symptom duration, physical and psychiatric comorbidity, disability, occupational functioning at follow-up and prognostic factors.

RESULTS

24 studies were included. There was heterogeneity regarding study size (number of patients (n)=10 491), follow-up duration clinical setting and data availability. Most studies (n=15) were retrospective. Reported symptom outcome was highly variable. Mean weighted follow-up duration was 7.4 years (in 13 studies where data was extractable). The mean percentage of patients same or worse at follow-up for all studies was 39%, range 10% to 90%, n=1134. Levels of physical disability and psychological comorbidity at follow-up were high. Short duration of symptoms, early diagnosis and high satisfaction with care predicted positive outcome in two studies. Gender had no effect. Delayed diagnosis and personality disorder were negatively correlated with outcome. Prognostic factors that varied between studies included age, comorbid anxiety and depression, IQ, educational status, marital status and pending litigation.

CONCLUSIONS

Existing follow-up studies of functional motor symptoms give us some insights regarding outcome and prognostic factors but are limited by their largely retrospective and selective nature. Overall, prognosis appears unfavourable. The severity and chronicity of functional motor symptoms argues for larger prospective studies including multiple prognostic factors at baseline in order to better understand their natural history.

Transcranial magnetic stimulation as an efficient treatment for psychogenic movement disorders

BACKGROUND

Management of psychogenic movement disorders (PMDs) is challenging for neurologists and, to date, there is no consensus about their treatment. Recent studies suggested a possible therapeutic effect of repeated transcranial magnetic stimulation (TMS) in psychogenic paralysis and tremor.

OBJECTIVE

To document the clinical impact of TMS in PMDs.

METHODS

We blindly video scored symptoms of consecutive patients with PMD who were recorded before and after TMS. TMS was delivered at low frequency (0.25 Hz) over the motor cortex contralateral to symptoms.

RESULTS

Twenty-four patients were included. They presented with dystonia, myoclonus, tremor, Parkinsonism or stereotypies. The median duration of symptoms before TMS was 2.8 years (6 months to 30 years). The overall score of 75% of patients improved by >50% and, furthermore, the clinical benefits were sustained upon protracted follow-up (median 19.8 months). There was no correlation between improvement and duration of symptoms before TMS.

CONCLUSIONS

TMS is a therapeutic option for PMDs, including chronic PMDs.

Psychogenic seizures and psychogenic movement disorders: are they the same patients?

Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are common and disabling problems with abnormal psychological profiles, and they may have common features that could aid in better understanding and management. Since PNES and PMD are investigated and reported separately, comparisons are lacking. Psychogenic nonepileptic seizure and psychogenic movement disorder patients completed demographic, clinical, and psychological inventories including the Short Form (SF)-12 Health Status Survey (Physical and Mental Health Summary Scores), the Brief Symptom Inventory (BSI)-18 (somatization, depression, and anxiety subscales), and the Lorig Self-Efficacy Scale. Psychogenic nonepileptic seizure and psychogenic movement disorder patients had similar psychological profiles with reduced SF-12 Physical Health and Mental Health Summary Scores and increased BSI somatization, depression, and anxiety ratings. They varied slightly in age and gender, but their main distinguishing features were the presenting signs. These similar profiles suggest that PNES and PMD may not be distinct or separate entities and that collaborative investigative efforts and management are warranted.

Psychogenic movement disorders

Psychogenic movement disorders are common, but the diagnosis may be difficult. Visual appearance alone is typically not sufficient to make a diagnosis, but such information is certainly important. That a movement is bizarre can be helpful, but still must be considered thoughtfully since organic movement disorders can have endless variety. The diagnosis should rest on positive findings such as paroxysmal nature, maximum severity at or near onset, variability of tremor direction, frequency and amplitude, entrainment of tremor, distractability and suggestibility, and wildly swaying gait and balance problems with no falling. Psychogenic parkinsonism often poses a problem because of the relatively high frequency of overlap of psychogenic and organic disease. In regard to psychogenic parkinsonism, there are special features to look for. There might be tremor with kinetic movement as well as rest and posture, and finger tremor might be absent. With sequential movements, the sequence effect is typically lacking. Extreme slowness and grunting with great effort may be seen. Improvement in arm swing while running, a feature of organic parkinsonism, may not be seen.

Functional (psychogenic) movement disorders

PURPOSE OF REVIEW

This review provides an overview of recent developments in diagnosis, pathophysiology, neuroimaging and management of functional (psychogenic) movement disorders (FMD).

RECENT FINDINGS

There has been increasing interest to study the underlying pathophysiology of FMD, which has resulted in a broadened disease model, taking neurobiologic and psychosocial factors equally into account. In this context, the term 'psychogenic' has been replaced by 'functional' movement disorders by many authors in the field to express the changing focus toward a multifactorial disease model. The need for establishing a positive diagnosis of FMD as opposed to providing a diagnosis of exclusion is increasingly recognized and reflected by the introduction of 'laboratory-supported' diagnostic criteria of FMD. Important advances have been made through behavioral, electrophysiological and neuroimaging studies, although the fundamental cause of FMD remains poorly understood. Of particular interest have been several reports on abnormal sensorimotor features and cortical inhibition in both organic and functional dystonia, highlighting possible shared traits of both conditions. In terms of treatment, recent studies have reported benefit from both psychiatric and physical therapy-based interventions.

SUMMARY

Increasing efforts have been made toward better understanding of FMD, and the disease model has been broadened to include neurobiologic and psychosocial factors. Laboratory-based diagnostic criteria have been established for many FMD to support the clinical diagnosis. To determine the most effective management strategies for FMD, a closer collaboration between neurologists and psychiatrists and intensified research efforts with prospective treatment trials are needed.

Functional (psychogenic) movement disorders: merging mind and brain

Functional (psychogenic) movement disorders (FMD) are part of the wide spectrum of functional neurological disorders, which together account for over 16% of patients referred to neurology clinics. FMD have been described as a "crisis for neurology" and cause major challenges in terms of diagnosis and treatment. As with other functional disorders, a key issue is the absence of pathophysiological understanding. There has been an influential historical emphasis on causation by emotional trauma, which is not supported by epidemiological studies. The similarity between physical signs in functional disorders and those that occur in feigned illness has also raised important challenges for pathophysiological understanding and has challenged health professionals' attitudes toward patients with these disorders. However, physical signs and selected investigations can help clinicians to reach a positive diagnosis, and modern pathophysiological research is showing an appreciation of the importance of both physical and psychological factors in FMD.

Psychogenic movement disorders: past developments, current status, and future directions

As the field of movement disorders has developed and matured over the past 25 years, psychogenic movement disorders have become increasingly recognized in subspecialty clinics. The diagnosis can be challenging and should be based on positive features rather than a purely exclusionary approach. The clinical phenotype can be quite varied, although certain categories of abnormal movement are more common than others. Electrophysiological studies may be particularly useful in establishing the diagnosis, especially with respect to tremor and myoclonus, and an argument can be made for adding a "laboratory-supported definite" category to earlier classification schemes. The diagnosis of psychogenic dystonia remains a major challenge, although there are some recent promising developments with respect to the evaluation of cortical plasticity that require further study. The pathogenesis of psychogenic movement disorders is poorly understood; insights may be provided from the study of other neurological conversion disorders such as psychogenic hemiparesis. Psychogenic movement disorders typically result in considerable disability and negatively impact quality of life to the same or greater extent than do many organic movement disorders. Treatment is extremely challenging, and many patients experience chronic disability despite various therapeutic interventions. Given the personal and societal impact of these problems, further advances in our understanding of their pathogenesis and the subsequent development of effective therapies are sorely needed.

Psychopathology and psychogenic movement disorders

Psychogenic movement disorder is defined as abnormal movements unrelated to a medical cause and presumed related to underlying psychological factors. Although psychological factors are of both clinical and pathophysiological relevance, very few studies to date have systematically assessed their role in psychogenic movement disorder. We sought to assess the role of previous life stress using validated quantitative measures in patients with psychogenic movement disorder compared with age- and sex-matched healthy volunteers as well as a convenience sample of patients with focal hand dystonia. Sixty-four patients with psychogenic movement disorder (72% female; mean age, 45.2 years [standard deviation, 15.2 years]), 38 healthy volunteers (74% female; mean age, 49 years [standard deviation, 13.7 years]), and 39 patients with focal hand dystonia (37% female; mean age, 48.7 years [standard deviation, 11.7 years]) were evaluated using a standardized psychological interview as well as validated quantitative scales to assess trauma and previous stressors, depression, anxiety, and personality traits. Patients with psychogenic movement disorder reported higher rates of childhood trauma, specifically greater emotional abuse and physical neglect, greater fear associated with traumatic events, and a greater number of traumatic episodes compared with healthy volunteers and patients with focal hand dystonia controlled for depressive symptoms and sex (Bonferroni corrected P < .005). There were no differences in categorical psychiatric diagnoses or scores on childhood physical or sexual abuse subscales, personality traits, or the dissociative experience scale. Our findings highlight a biopsychosocial approach toward the pathophysiology of psychogenic movement disorder, although the association with psychological issues is much less prominent than expected compared with the nonepileptic seizure population. A careful psychological assessment is indicated to optimize therapeutic modalities.

Psychogenic movement disorders in children

Psychogenic movement disorders (PMDs) are well characterized in adults, but childhood-onset PMDs have not been extensively studied. We reviewed the medical records of children who were diagnosed in our clinic with PMDs since 1988 and identified 54 patients with PMDs, representing 3.1% of our pediatric movement disorder population and 5.7% of all PMD cases. The mean age at symptom onset was 14.2 years (+/-2.11, range 7.6-17.7). Similar to published data in adults, two-thirds of children exhibited multiple PMD phenotypes, the most common being tremor followed by dystonia and myoclonus. Most PMDs were abrupt in onset, paroxysmal and triggered by identifiable physical or psychological trauma. As in adults, childhood PMDs were more likely to affect females, but there was no female predominance in children less than 13 years old. Although prior studies suggest that medically unexplained symptoms beginning in childhood often follow a benign course, this cohort of children experienced marked disability and morbidity related to PMDs, including prolonged school absences and unnecessary surgical procedures in more than one-fifth of patients.

Quality of life and neurotic disorders in general healthcare

PURPOSE OF REVIEW

To review recent findings on the relationship between neurotic disorders (specifically depression, anxiety and somatization) and function and quality of life (QoL) in patients with complex clinical presentations, and to consider the clinical and public health implications.

RECENT FINDINGS

The high prevalence of comorbid depression and anxiety among patients with general medical disorders is well known. The impact of the comorbidity on function in these patients is documented extensively. The study of their QoL is an emerging area of work, though its interpretation is controversial. The impact of somatization on function and QoL is less well studied. Recent findings emphasize the value of a common measure for QoL across health conditions.

SUMMARY

Depression, anxiety and somatization are a significant burden in the general population and failure to recognize and manage these problems in general healthcare contributes to delayed recovery. A holistic approach to symptom, disability and QoL assessment, done in awareness of possible measurement redundancy, is likely to assist better recognition and management of these conditions. Further research is needed on the effects on QoL of depression and anxiety in patients with general medical disorders and early detection and treatment of somatization.