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Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
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Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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Abstract
PURPOSE OF REVIEW This article reviews a practical approach to psychogenic movement disorders to help neurologists identify and manage this complex group of disorders. RECENT FINDINGS Psychogenic movement disorders, also referred to as functional movement disorders, describe a group of disorders that includes tremor, dystonia, myoclonus, parkinsonism, speech and gait disturbances, and other movement disorders that are incongruent with patterns of pathophysiologic (organic) disease. The diagnosis is based on positive clinical features that include variability, inconsistency, suggestibility, distractibility, suppressibility, and other supporting information. While psychogenic movement disorders are often associated with psychological and physical stressors, the underlying pathophysiology is not fully understood. Although insight-oriented behavioral and pharmacologic therapies are helpful, a multidisciplinary approach led by a neurologist, but also including psychiatrists and physical, occupational, and speech therapists, is needed for optimal outcomes. SUMMARY The diagnosis of psychogenic movement disorders is based on clinical features identified on neurologic examination, and neurophysiologic and imaging studies can provide supporting information.
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3
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Onofrj M, Espay AJ, Bonanni L, Delli Pizzi S, Sensi SL. Hallucinations, somatic-functional disorders of PD-DLB as expressions of thalamic dysfunction. Mov Disord 2019; 34:1100-1111. [PMID: 31307115 DOI: 10.1002/mds.27781] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/30/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022] Open
Abstract
Hallucinations, delusions, and functional neurological manifestations (conversion and somatic symptom disorders) of Parkinson's disease (PD) and dementia with Lewy bodies increase in frequency with disease progression, predict the onset of cognitive decline, and eventually blend with and are concealed by dementia. These symptoms share the absence of reality constraints and can be considered comparable elements of the PD-dementia with Lewy bodies psychosis. We propose that PD-dementia with Lewy bodies psychotic disorders depend on thalamic dysfunction promoting a theta burst mode and subsequent thalamocortical dysrhythmia with focal cortical coherence to theta electroencephalogram rhythms. This theta electroencephalogram activity, also called fast-theta or pre-alpha, has been shown to predict cognitive decline and fluctuations in Parkinson's disease with dementia and dementia with Lewy bodies. These electroencephalogram alterations are now considered a predictive marker for progression to dementia. The resulting thalamocortical dysrhythmia inhibits the frontal attentional network and favors the decoupling of the default mode network. As the default mode network is involved in integration of self-referential information into conscious perception, unconstrained default mode network activity, as revealed by recent imaging studies, leads to random formation of connections that link strong autobiographical correlates to trivial stimuli, thereby producing hallucinations, delusions, and functional neurological disorders. The thalamocortical dysrhythmia default mode network decoupling hypothesis provides the rationale for the design and testing of novel therapeutic pharmacological and nonpharmacological interventions in the context of PD, PD with dementia, and dementia with Lewy bodies. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Italy
| | - Alberto J Espay
- Department of Neurology, James J. and Joan A. Gardner Family Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Italy
| | - Stefano Delli Pizzi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Italy
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Italy.,Departments of Neurology and Pharmacology, Institute for Mind Impairments and Neurological Disorders, University of California - Irvine, Irvine, California, USA
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4
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Restrepo M, Restrepo D. From Conversion Disorders to Functional Neurological Disorders. Overcoming the Rule-out Diagnosis? REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2019; 48:174-181. [PMID: 31426920 DOI: 10.1016/j.rcp.2017.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/23/2017] [Accepted: 10/22/2017] [Indexed: 06/10/2023]
Abstract
Functional neurological disorders, formerly referred to as conversion disorders, are a frequent clinical problem in neurology, psychiatry and primary care departments. In the new diagnostic categories, emphasis is placed on the positive characteristics necessary to diagnose this disorder. A narrative review of the scientific medical literature related to the subject was performed in order to determine the differences and advantages that the new classification of functional neurological disorders gives to doctors and patients. Historical, diagnostic, clinical and treatment concepts related to functional neurological disorders are reviewed. The conceptual differences between conversion disorders and functional neurological disorders and the implications of these changes in the clinical approach are identified. The new proposed diagnosis for functional neurological disorders provides the opportunity to transform a diagnosis made by ruling out other pathologies to a diagnosis where the presence of neurological signs suggestive of the disorder are verified and can be taught to the patient, and based on them, treatment strategies posed.
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5
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Baizabal-Carvallo JF, Hallett M, Jankovic J. Pathogenesis and pathophysiology of functional (psychogenic) movement disorders. Neurobiol Dis 2019; 127:32-44. [PMID: 30798005 DOI: 10.1016/j.nbd.2019.02.013] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 11/17/2022] Open
Abstract
Functional movement disorders (FMDs), known over time as "hysteria", "dissociative", "conversion", "somatoform", "non-organic" and "psychogenic" disorders, are characterized by having a voluntary quality, being modifiable by attention and distraction but perceived by the patient as involuntary. Although a high prevalence of depression and anxiety is observed in these patients, a definitive role of psychiatric disorders in FMDs has not been proven, and many patients do not endorse such manifestations. Stressful events, social influences and minor trauma may precede the onset of FMDs, but their pathogenic mechanisms are unclear. Patients with FMDs have several abnormalities in their neurobiology including strengthened connectivity between the limbic and motor networks. Additionally, there is altered top-down regulation of motor activities and increased activation of areas implicated in self-awareness, self-monitoring, and active motor inhibition such as the cingulate and insular cortex. Decreased activation of the supplementary motor area (SMA) and pre-SMA, implicated in motor control and preparation, is another finding. The sense of agency defined as the feeling of controlling external events through one's own action also seems to be impaired in individuals with FMDs. Correlating with this is a loss of intentional binding, a subjective time compression between intentional action and its sensory consequences. Organic and functional dystonia may be difficult to differentiate since they share diverse neurophysiological features including decreased cortical inhibition, and similar local field potentials in the globus pallidus and thalamus; although increased cortical plasticity is observed only in patients with organic dystonia. Advances in the pathogenesis and pathophysiology of FMDs may be helpful to understand the nature of these disorders and plan further treatment strategies.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; University of Guanajuato, Mexico.
| | - Mark Hallett
- Human Motor Control Section, NINDS, National Institutes of Health, Bethesda, MD, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Onofrj M, Carrozzino D, D’Amico A, Di Giacomo R, Delli Pizzi S, Thomas A, Onofrj V, Taylor JP, Bonanni L. Psychosis in parkinsonism: an unorthodox approach. Neuropsychiatr Dis Treat 2017; 13:1313-1330. [PMID: 28553118 PMCID: PMC5439966 DOI: 10.2147/ndt.s116116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Psychosis in Parkinson's disease (PD) is currently considered as the occurrence of hallucinations and delusions. The historical meaning of the term psychosis was, however, broader, encompassing a disorganization of both consciousness and personality, including behavior abnormalities, such as impulsive overactivity and catatonia, in complete definitions by the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Our review is aimed at reminding that complex psychotic symptoms, including impulsive overactivity and somatoform disorders (the last being a recent controversial entity in PD), were carefully described in postencephalitic parkinsonism (PEP), many decades before dopaminergic treatment era, and are now described in other parkinsonisms than PD. Eminent neuropsychiatrists of the past century speculated that studying psychosis in PEP might highlight its mechanisms in other conditions. Yet, functional assessments were unavailable at the time. Therefore, the second part of our article reviews the studies of neural correlates of psychosis in parkinsonisms, by taking into account both theories on the narrative functions of the default mode network (DMN) and hypotheses on DMN modulation.
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Affiliation(s)
- Marco Onofrj
- Department of Neuroscience Imaging and Clinical Sciences, University “G. d’Annunzio” of Chieti-Pescara
- CE.S.I. University Foundation
| | - Danilo Carrozzino
- Department of Psychological, Health, and Territorial Sciences, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
- Psychiatric Research Unit, Psychiatric Centre North Zealand, Copenhagen University Hospital, Hillerød, Denmark
| | - Aurelio D’Amico
- Department of Neuroscience Imaging and Clinical Sciences, University “G. d’Annunzio” of Chieti-Pescara
- CE.S.I. University Foundation
| | - Roberta Di Giacomo
- Department of Neuroscience Imaging and Clinical Sciences, University “G. d’Annunzio” of Chieti-Pescara
- CE.S.I. University Foundation
| | - Stefano Delli Pizzi
- Department of Neuroscience Imaging and Clinical Sciences, University “G. d’Annunzio” of Chieti-Pescara
| | - Astrid Thomas
- Department of Neuroscience Imaging and Clinical Sciences, University “G. d’Annunzio” of Chieti-Pescara
- CE.S.I. University Foundation
| | - Valeria Onofrj
- Department of Bioimaging, University Cattolica del Sacro Cuore, Rome, Italy
| | - John-Paul Taylor
- Institute of Neuroscience, Campus for Ageing and Vitality Newcastle University Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Laura Bonanni
- Department of Neuroscience Imaging and Clinical Sciences, University “G. d’Annunzio” of Chieti-Pescara
- CE.S.I. University Foundation
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7
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Pringsheim T, Edwards M. Functional movement disorders: Five new things. Neurol Clin Pract 2017; 7:141-147. [PMID: 29185540 PMCID: PMC5669411 DOI: 10.1212/cpj.0000000000000350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/23/2017] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Functional movement disorders (FMD) are commonly seen in neurologic practice, but are associated with poor outcomes. Recent years have seen a resurgence of interest in this area, with new developments in pathophysiologic understanding and therapeutic management. RECENT FINDINGS Individuals with FMD are a psychologically heterogeneous group, with many individuals having no detectable psychopathology on symptom screening measures, and possibly significant etiologically relevant life events only revealed through in-depth interviews. A randomized trial of specialist intensive physical rehabilitation compared to community-based neurophysiotherapy in FMD has demonstrated moderate to large effect sizes for both physical and social functioning outcomes. Experimental evidence suggests an impairment in the neural systems conferring a sense of agency over movement in individuals with FMD, and may explain why movements that appear voluntary are not experienced as such. SUMMARY The prognosis of individuals with FMD may be improved with greater access to appropriately organized care and treatment.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (TP), University of Calgary, Canada; and St George's University of London (ME), UK
| | - Mark Edwards
- Department of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (TP), University of Calgary, Canada; and St George's University of London (ME), UK
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Rommelfanger KS, Factor SA, LaRoche S, Rosen P, Young R, Rapaport MH. Disentangling Stigma from Functional Neurological Disorders: Conference Report and Roadmap for the Future. Front Neurol 2017; 8:106. [PMID: 28424653 PMCID: PMC5372777 DOI: 10.3389/fneur.2017.00106] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/03/2017] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Karen S Rommelfanger
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.,Department of Neurology, Emory University, Atlanta, GA, USA.,Center for Ethics Neuroethics Program, Emory University, Atlanta, GA, USA
| | | | - Suzette LaRoche
- Department of Neurology, Emory University, Atlanta, GA, USA.,Mission Health, Epilepsy Center, Asheville, NC, USA
| | - Phyllis Rosen
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Raymond Young
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Mark H Rapaport
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
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9
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Yu MM, Weathers AL, Wu AD, Evans DA. Sharing notes with patients: A review of current practice and considerations for neurologists. Neurol Clin Pract 2017; 7:179-185. [PMID: 29185532 DOI: 10.1212/cpj.0000000000000335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/26/2016] [Indexed: 11/15/2022]
Abstract
Improved patient engagement is a critical consideration in the new payment climate. Releasing progress notes for patients to view may improve patient involvement and engagement in their care. Patients perceive benefit from viewing physician progress notes. As initial studies involved only primary care physicians, specialist physicians may have specific considerations when releasing notes to patients. This article provides a framework for neurologists to implement a note release policy in their practice.
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Affiliation(s)
- Melissa M Yu
- Department of Neurology (MMY), Baylor College of Medicine, Houston, TX; Department of Neurological Sciences (ALW), Rush University Medical Center, Chicago, IL; Department of Neurology (ADW), David Geffen School of Medicine, University of California Los Angeles; (DAE) Texas Neurology, Dallas
| | - Allison L Weathers
- Department of Neurology (MMY), Baylor College of Medicine, Houston, TX; Department of Neurological Sciences (ALW), Rush University Medical Center, Chicago, IL; Department of Neurology (ADW), David Geffen School of Medicine, University of California Los Angeles; (DAE) Texas Neurology, Dallas
| | - Allan D Wu
- Department of Neurology (MMY), Baylor College of Medicine, Houston, TX; Department of Neurological Sciences (ALW), Rush University Medical Center, Chicago, IL; Department of Neurology (ADW), David Geffen School of Medicine, University of California Los Angeles; (DAE) Texas Neurology, Dallas
| | - David A Evans
- Department of Neurology (MMY), Baylor College of Medicine, Houston, TX; Department of Neurological Sciences (ALW), Rush University Medical Center, Chicago, IL; Department of Neurology (ADW), David Geffen School of Medicine, University of California Los Angeles; (DAE) Texas Neurology, Dallas
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10
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Newby R, Alty J, Kempster P. Functional dystonia and the borderland between neurology and psychiatry: New concepts. Mov Disord 2016; 31:1777-1784. [PMID: 27753149 DOI: 10.1002/mds.26805] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/21/2016] [Accepted: 08/29/2016] [Indexed: 01/07/2023] Open
Abstract
Mind-brain dualism has dominated historical commentary on dystonia, a dichotomous approach that has left our conceptual grasp of it stubbornly incomplete. This is particularly true of functional dystonia, most diagnostically challenging of all functional movement disorders, in which the question of inherent psychogenicity remains a focus of debate. Phenomenological signs considered in isolation lack the specificity to distinguish organic and nonorganic forms, and dystonia's variability has frustrated attempts to develop objective laboratory-supported standards. Diagnostic criteria for functional dystonia that place emphasis on psychiatric symptoms perform poorly in studies of reliability, partly explained by the high frequency of psychopathology in organic dystonia. Novel approaches from the cognitive neurosciences may offer a way forward. Theory on Bayesian statistical prediction in cognitive processing is supported by sufficient experimental evidence for this model to be taken seriously as a way of reconciling contradictory notions about voluntary and unconscious motor control in functional movement disorders. In a Bayesian formulation of functional dystonia, misallocation of attention and abnormal predictive beliefs generate movements that are executed without a sense of agency. Building on this framework, there is a consensus that a biopsychosocial approach is required and that a unified philosophy of brain and mind is the best way to locate dystonia in the neurology-psychiatry borderland. At a practical level, movement disorder neurologists are best placed to differentiate organic from functional dystonia. The main role of psychiatrists is in the diagnosis and management of the primarily psychiatric disorders that often accompany dystonia. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Rachel Newby
- Neurosciences Department, Monash Medical Centre, Clayton, Victoria, Australia.,Department of Neurology, Leeds General Infirmary, Leeds, UK
| | - Jane Alty
- Department of Neurology, Leeds General Infirmary, Leeds, UK
| | - Peter Kempster
- Neurosciences Department, Monash Medical Centre, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
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Stone J, Hoeritzauer I, Gelauff J, Lehn A, Gardiner P, van Gils A, Carson A. Functional Disorders in Neurology. Neurol Clin 2016; 34:667-81. [DOI: 10.1016/j.ncl.2016.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Can motor imagery and hypnotic susceptibility explain Conversion Disorder with motor symptoms? Neuropsychologia 2016; 89:287-298. [PMID: 27346334 DOI: 10.1016/j.neuropsychologia.2016.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/08/2016] [Accepted: 06/22/2016] [Indexed: 11/24/2022]
Abstract
Marked distortions in sense of agency can be induced by hypnosis in susceptible individuals, including alterations in subjective awareness of movement initiation and control. These distortions, with associated disability, are similar to those experienced with Conversion Disorder (CD), an observation that has led to the hypothesis that hypnosis and CD share causal mechanisms. The purpose of this review is to explore the relationships among motor imagery (MI), hypnotic susceptibility, and CD, then to propose how MI ability may contribute to hypnotic responding and CD. Studies employing subjective assessments of mental imagery have found little association between imagery abilities and hypnotic susceptibility. A positive association between imagery abilities and hypnotic susceptibility becomes apparent when objective measures of imagery ability are employed. A candidate mechanism to explain motor responses during hypnosis is kinaesthetic MI, which engages a strategy that involves proprioception or the "feel" of movement when no movement occurs. Motor suppression imagery (MSI), a strategy involving inhibition of movement, may provide an alternate objective measurable phenomenon that underlies both hypnotic susceptibility and CD. Evidence to date supports the idea that there may be a positive association between kinaesthetic MI ability and hypnotic susceptibility. Additional evidence supports a positive association between hypnotic susceptibility and CD. Disturbances in kinaesthetic MI performance in CD patients indicate that MI mechanisms may also underlie CD symptoms. Further investigation of the above relationships is warranted to explain these phenomena, and establish theoretical explanations underlying sense of agency.
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Kaski D, Bronstein AM, Edwards MJ, Stone J. Cranial functional (psychogenic) movement disorders. Lancet Neurol 2016; 14:1196-205. [PMID: 26581970 DOI: 10.1016/s1474-4422(15)00226-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/21/2015] [Accepted: 08/27/2015] [Indexed: 01/15/2023]
Abstract
Functional (psychogenic) neurological symptoms are frequently encountered in neurological practice. Cranial movement disorders--affecting the eyes, face, jaw, tongue, or palate--are an under-recognised feature of patients with functional symptoms. They can present in isolation or in the context of other functional symptoms; in particular, for functional eye movements, positive clinical signs such as convergence spasms can be triggered by the clinical examination. Although the specialty of functional neurological disorders has expanded, appreciation of cranial functional movement disorders is still insufficient. Identification of the positive features of cranial functional movement disorders such as convergence and unilateral platysmal spasm might lend diagnostic weight to a suspected functional neurological disorder. Understanding of the differential diagnosis, which is broad and includes many organic causes (eg, stroke), is essential to make an early and accurate diagnosis to prevent complications and initiate appropriate management. Increased understanding of these disorders is also crucial to drive clinical trials and studies of individually tailored therapies.
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Affiliation(s)
- Diego Kaski
- Department of Neuro-otology, National Hospital for Neurology and Neurosurgery, London, UK; Division of Brain Sciences, Imperial College London, Charing Cross Hospital, London, UK.
| | - Adolfo M Bronstein
- Department of Neuro-otology, National Hospital for Neurology and Neurosurgery, London, UK; Division of Brain Sciences, Imperial College London, Charing Cross Hospital, London, UK
| | - Mark J Edwards
- Department of Neuro-otology, National Hospital for Neurology and Neurosurgery, London, UK; Sobell Department of Motor Neuroscience and Movement, UCL Institute of Neurology, London, UK
| | - Jon Stone
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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14
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Abstract
PURPOSE OF REVIEW Functional neurologic disorders, also called psychogenic, nonorganic, conversion, and dissociative disorders, are among the most common problems in neurologic practice. This article presents a practical guide to clinical assessment and treatment, incorporating emerging research evidence. This article places an emphasis on encouraging neurologists to use the assessment as treatment, take an active role in educating and treating the patient, and work in a multidisciplinary way with psychiatry, psychology, and physical therapy. RECENT FINDINGS Classification of functional neurologic disorders now emphasizes the importance of positive diagnosis based on physical signs, not psychological features. Studies of mechanism have produced new clinical and neurobiological ways of thinking about these disorders. Evidence has emerged to support the use of physical therapy for functional movement disorders and psychotherapy for dissociative (nonepileptic) attacks. SUMMARY The diagnosis and management of functional neurologic disorders has entered a new evidence-based era and deserves a standard place in the neurologic curriculum.
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15
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Carson A, Lehn A, Ludwig L, Stone J. Explaining functional disorders in the neurology clinic: a photo story. Pract Neurol 2016; 16:56-61. [DOI: 10.1136/practneurol-2015-001242] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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16
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Williams DT, Lafaver K, Carson A, Fahn S. Inpatient treatment for functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:631-641. [PMID: 27719878 DOI: 10.1016/b978-0-12-801772-2.00051-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Patients with functional neurologic disorders present to clinicians with a variety of symptomatic manifestations, with various levels of severity, chronicity, and comorbidity, as well as with various degrees of past adversity, intrinsic resilience, and available external support. Clearly, treatment must be individualized. For those patients who have been severely or chronically impaired, especially if adequate prior outpatient treatments have failed, inpatient treatment that integrates the various modalities outlined here provides a rational route of rescue from a course otherwise potentially characterized by protracted dependence and disability. Based on the data currently available, we believe this treatment approach is worthy of further study to refine the component treatment strategies and enhance the potentially most effective ingredients. For patients with severe levels of disability, who could be managed in a multimodal day-treatment program, that approach also warrants further consideration.
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Affiliation(s)
- D T Williams
- Movement Disorders Division, Columbia University Medical Center and Department of Psychiatry, Columbia College of Physicians and Surgeons, New York, NY, USA.
| | - K Lafaver
- Movement Disorders Clinic, University of Louisville, Louisville, KY, USA
| | - A Carson
- Departments of Clinical Neurosciences and of Rehabilitation Medicine, NHS Lothian and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - S Fahn
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
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17
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Stone J, Carson A, Hallett M. Explanation as treatment for functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:543-553. [PMID: 27719870 DOI: 10.1016/b978-0-12-801772-2.00044-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is widespread agreement that the way health professionals communicate the diagnosis of functional neurologic disorders (FND) has a central role in treatment, as it does arguably for most conditions. In this chapter we discuss barriers to effective diagnosis, different models of explanation and evidence regarding the importance of effective communication of the diagnosis in FND, especially movement disorders, and dissociative (nonepileptic) seizures. Debates and disagreements about how to go about this task often reflect different theoretic models held by health professionals rather than evidence. More evidence is required to know whether an initial emphasis on one model is more or less effective than another (e.g., a functional model vs. a psychologic model). We conclude, however, that there are a number of generic components to effective explanation shared by most authors on the topic that form the basis of a consensus. These include taking the patient seriously, giving the problem a diagnostic label, explaining the rationale for the diagnosis, some discussion of how the symptoms arise, emphasis on the potential for reversibility (rather than damage), and effective triage and referral for other treatment where appropriate. Although explanation can sometimes be therapeutic on its own, its role is probably more important as a facilitator to other therapy, including self-help, physical treatments, and psychotherapy.
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Affiliation(s)
- J Stone
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - A Carson
- Departments of Clinical Neurosciences and of Rehabilitation Medicine, NHS Lothian and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - M Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Abstract
Functional neurologic disorders (FND) of children have many similarities to those of adults, and there is a potential to learn much from the study of FND in children. In this chapter we discuss multiple aspects of pediatric FND. These include their frequency, historic features, the diagnosis, and controversies over the nature of FND and the "correct" name that should be used. We also discuss methods of informing the child and family of the diagnosis, treatment, and prognosis. FND of children typically affect girls in the 10-14-years age range. The presentation is often polysymptomatic, with pain and lethargy accompanying loss of motor function. A common situation is a perfectionistic child who has taken on too much in her academic, sporting, cultural, and social life. Some children respond readily to treatment, but others have a prolonged illness.
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Affiliation(s)
- P J Grattan-Smith
- Department of Neurology, Westmead Children's Hospital, Sydney, Australia.
| | - R C Dale
- Department of Neurology, Westmead Children's Hospital, Sydney, Australia
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Stone J. Functional neurological disorders: the neurological assessment as treatment. Pract Neurol 2015; 16:7-17. [DOI: 10.1136/practneurol-2015-001241] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 11/03/2022]
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Puccioni-Sohler M, Ramos JTMA, Rosadas C, Vasconcellos LF. Psychogenic movement disorder in human T-lymphotropic virus type 1 associated myelopathy. Int J Infect Dis 2015; 42:47-49. [PMID: 26603645 DOI: 10.1016/j.ijid.2015.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/09/2015] [Accepted: 11/13/2015] [Indexed: 11/16/2022] Open
Abstract
Human T-lymphotropic virus type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is a chronic inflammatory disorder of the spinal cord. Acute cases of HAM/TSP and those complicated by movement disorders are rarely reported. Otherwise, psychiatric disturbances are very frequent in infected patients. It can evolve to psychogenic disorders. The case of a 46-year-old woman with acute HAM/TSP complicated by depression and psychogenic movement disorders (chorea of the hands and dystonia-like facial symptoms) is reported. Brain magnetic resonance imaging revealed non-specific small white matter lesions. The involuntary movements arose suddenly and disappeared when the patient was distracted. Two years of psychotherapy and psychiatric follow-up induced complete remission of the symptoms. The association of psychogenic movement disorders and HAM/TSP, increasing the range of neurological manifestations associated with HTLV-1, is related here. Early diagnosis of psychogenic movement disorders is very important to improve the prognosis and treatment of the two conditions, thereby improving the quality of life of HAM/TSP patients and avoiding irreversible sequelae.
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Affiliation(s)
- Marzia Puccioni-Sohler
- Neuroinfection Clinic, Hospital Universitário Gaffrée e Guinle (HUGG), Universidade Federal do Estado do Rio de Janeiro (UNIRIO), R. Mariz e Barros, 775, Rio de Janeiro, RJ, CEP 20270-901, Brazil; CSF Laboratory and Post-Graduation in Infectious and Parasitic Diseases, Universidade Federal do Rio de Janeiro (UFRJ), Cidade Universitária - Ilha do Fundão, Rio de Janeiro, RJ, Brazil.
| | - Jessyca T M A Ramos
- Neuroinfection Clinic, Hospital Universitário Gaffrée e Guinle (HUGG), Universidade Federal do Estado do Rio de Janeiro (UNIRIO), R. Mariz e Barros, 775, Rio de Janeiro, RJ, CEP 20270-901, Brazil
| | - Carolina Rosadas
- CSF Laboratory and Post-Graduation in Infectious and Parasitic Diseases, Universidade Federal do Rio de Janeiro (UFRJ), Cidade Universitária - Ilha do Fundão, Rio de Janeiro, RJ, Brazil
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From conversion disorder (DSM-IV-TR) to functional neurological symptom disorder (DSM-5): When a label changes the perspective for the neurologist, the psychiatrist and the patient. J Neurol Sci 2015; 360:55-6. [PMID: 26723973 DOI: 10.1016/j.jns.2015.11.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/20/2015] [Accepted: 11/13/2015] [Indexed: 11/23/2022]
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Dallocchio C, Marangi A, Tinazzi M. Functional or psychogenic movement disorders: an endless enigmatic tale. Front Neurol 2015; 6:37. [PMID: 25774148 PMCID: PMC4343003 DOI: 10.3389/fneur.2015.00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/15/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
- Carlo Dallocchio
- Division of Neurology, Ospedale Civile, Azienda Ospedaliera Della Provincia Di Pavia , Voghera , Italy
| | - Antonio Marangi
- Section of Neurology, Department of Neurological and Movement Sciences, University Hospital of Verona , Verona , Italy
| | - Michele Tinazzi
- Section of Neurology, Department of Neurological and Movement Sciences, University Hospital of Verona , Verona , Italy
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Brigo F, Igwe SC, Ausserer H, Nardone R, Tezzon F, Bongiovanni LG, Tinazzi M, Trinka E. Terminology of psychogenic nonepileptic seizures. Epilepsia 2015; 56:e21-5. [DOI: 10.1111/epi.12911] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Francesco Brigo
- Section of Clinical Neurology; Department of Neurological and Movement Sciences; University of Verona; Verona Italy
- Department of Neurology; Franz Tappeiner Hospital; Merano Italy
| | - Stanley C. Igwe
- Department of Neuro-Psychiatry; Federal Teaching Hospital; Abakaliki Ebonyi State Nigeria
| | - Harald Ausserer
- Department of Neurology; Franz Tappeiner Hospital; Merano Italy
| | - Raffaele Nardone
- Department of Neurology; Franz Tappeiner Hospital; Merano Italy
- Department of Neurology; Christian Doppler Klinic; Paracelsus Medical University, and Centre for Cognitive Neuroscience; Salzburg Austria
| | - Frediano Tezzon
- Department of Neurology; Franz Tappeiner Hospital; Merano Italy
| | - Luigi Giuseppe Bongiovanni
- Section of Clinical Neurology; Department of Neurological and Movement Sciences; University of Verona; Verona Italy
| | - Michele Tinazzi
- Section of Clinical Neurology; Department of Neurological and Movement Sciences; University of Verona; Verona Italy
| | - Eugen Trinka
- Department of Neurology; Christian Doppler Klinic; Paracelsus Medical University, and Centre for Cognitive Neuroscience; Salzburg Austria
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Baizabal-Carvallo JF, Fekete R. Recognizing uncommon presentations of psychogenic (functional) movement disorders. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2015; 5:279. [PMID: 25667816 PMCID: PMC4303603 DOI: 10.7916/d8vm4b13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/23/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Psychogenic 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. METHODS In 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. RESULTS Psychogenic 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. DISCUSSION Clinical features and ancillary studies are helpful in the diagnosis of patients with uncommon presentations of psychogenic movement disorders.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA ; University of Guanajuato, Mexico
| | - Robert Fekete
- Department of Neurology, New York Medical College, Valhalla, NY, USA
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LaFaver K, Hallett M. Functional or psychogenic: what's the better name? Mov Disord 2014; 29:1698-9. [PMID: 25242623 PMCID: PMC5681356 DOI: 10.1002/mds.26035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 06/10/2014] [Accepted: 08/24/2014] [Indexed: 11/06/2022] Open
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Fahn S, Olanow CW. Reply to: Psychogenic movement disorders: What's in a name? Mov Disord 2014; 29:1699-701. [DOI: 10.1002/mds.26042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 08/24/2014] [Indexed: 11/06/2022] Open
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28
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Edwards MJ, Stone J, Lang AE. Functional/psychogenic movement disorders: do we know what they are? Mov Disord 2014; 29:1696-7; discussion 1699-701. [PMID: 25284581 DOI: 10.1002/mds.26039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 06/29/2014] [Accepted: 08/24/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Mark J Edwards
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, UCL, Queen Square, London, United Kingdom
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Jankovic J. “Psychogenic” versus “functional” movement disorders? That is the question. Mov Disord 2014; 29:1697-8. [DOI: 10.1002/mds.26040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 08/24/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Joseph Jankovic
- Department of Neurology; Baylor College of Medicine; Houston Texas USA
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Ganos C, Erro R, Bhatia KP, Tinazzi M. Comment on psychogenic versus functional movement disorders. Mov Disord 2014; 29:1696. [DOI: 10.1002/mds.26038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 08/24/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Christos Ganos
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology; University College London; London United Kingdom
- Department of Neurology; University Medical Center Hamburg-Eppendorf (UKE); Hamburg Germany
| | - Roberto Erro
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology; University College London; London United Kingdom
| | - Kailash P. Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology; University College London; London United Kingdom
| | - Michele Tinazzi
- Department of Neurological and Movement Sciences; University of Verona; Verona Italy
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