Psychiatric disorders in idiopathic-isolated focal dystonia

Mood symptoms in cervical dystonia: Relationship with motor symptoms and quality of life

Background

Cervical dystonia (CD) has a high prevalence of anxiety and depression. The relationship between motor severity, mood symptoms and QoL is unclear and how to adequately assess these is also unknown. Instruments like the BAI, BDI and HADS are often used but items within these relating to somatic symptoms might influence the results.

Methods

Patients with idiopathic cervical dystonia (CD) were included. The BAI, BDI, HADS, CIDP58 and TWSTRS2- severity score were used for assessment of motor, mood and QoL symptoms. Pearson's correlations between motor and non-motor symptom scores were assessed. The psychometric properties of the psychiatric tools were measured and principal component analysis performed after identifying items that could correspond to somatic symptoms.

Results

201 participants were included. 42% of participants had either significant depression or anxiety symptoms or both when measured by BAI and BDI and 51% of patients met criteria on HADS. HADS-A and HADS-D, BAI and BDI were poorly correlated with TWSTRS2-S. The HADS-A and HADS-D both showed strong correlation with the sleep subdomain of CDIP58. Psychometric and principal component analysis on 149/201 participants did not reveal factor loadings consistent with the a priori somatic groupings. However mean scores were higher for somatic items.

Conclusion

A good score on the CDIP58, a commonly used tool, does not indicate mild disease severity or minimal mood symptoms. Minimal motor symptoms, similarly, also does not imply a positive QoL. Clinicians should be mindful on ideal methods for performing a holistic assessment of CD patients. This likely warrants a combination of motor, QoL and mood assessment tools.

[Mental disorders in blepharospasm]

OBJECTIVE

To analyze mental disorders in blepharospasm (BS) before and after botulinum therapy (BT).

MATERIAL AND METHODS

We examined 25 patients with BS (9 men and 16 women), aged 50 to 85 years (mean 64.1±18.5), with BS (main study group). The control group consisted of 20 healthy individuals (7 men and 13 women, mean age 63.5±8.5). Patients were examined before and after BT (after 3 weeks) using a diagnostic structured interview Mini International Neuropsychiatric Interview, GAD-7, PHQ-9, fear of negative assessment (short version) and The Liebowitz Social Anxiety Scale (LSAS).

RESULTS

Fifty-six percent of patients with BS, as assessed by the GAD-7, showed a high level of anxiety, while depression, measured by the PHQ-9 and found in 52% of patients, was mainly manifested by mild disorders. In the group of patients with BS, the mean scores were higher on the GAD-7, PHQ-9, fear of negative assessment (p<0.001) and LSAS (p<0.05) than in the control group. After treatment with BT, the levels of anxiety and depression in patients with BS decreased slightly and remained higher compared with the control group. Psychiatric examination in the majority (64%) of patients revealed mental disorders that could not be explained by the occurrence of BS. The remaining 36% of patients had adaptation disorders (nosogenic reactions) caused by BS. Affective mental pathology (recurrent depressive disorder and dysthymia) and anxiety disorders (social phobia and adjustment disorders) were more often observed in the main study group compared with the control group (24% versus 5% and 68% versus 10%, respectively).

CONCLUSION

A significant proportion of patients with BS have anxiety and depressive disorders, the severity of which does not depend only on the severity of motor symptoms and does not significantly decrease after successful BT, but is caused by mental disorders that preceded the manifestation of BS. Identification of mental disorders to varying degrees associated with BS, not only on the basis of psychometric scales, but also consultation with a psychiatrist, will allow, in addition to the correction of motor symptoms of BS, to differentiate the therapeutic approach through psychotherapy and psychopharmacotherapy.

Longitudinal analysis of the relationship between motor and psychiatric symptoms in idiopathic dystonia

BACKGROUND AND PURPOSE

Although psychiatric diagnoses are recognized in idiopathic dystonia, no previous studies have examined the temporal relationship between idiopathic dystonia and psychiatric diagnoses at scale. Here, we determine rates of psychiatric diagnoses and psychiatric medication prescription in those diagnosed with idiopathic dystsuponia compared to matched controls.

METHODS

A longitudinal population-based cohort study using anonymized electronic health care data in Wales (UK) was conducted to identify individuals with idiopathic dystonia and comorbid psychiatric diagnoses/prescriptions between 1 January 1994 and 31 December 2017. Psychiatric diagnoses/prescriptions were identified from primary and secondary health care records.

RESULTS

Individuals with idiopathic dystonia (n = 52,589) had higher rates of psychiatric diagnosis and psychiatric medication prescription when compared to controls (n = 216,754, 43% vs. 31%, p < 0.001; 45% vs. 37.9%, p < 0.001, respectively), with depression and anxiety being most common (cases: 31% and 28%). Psychiatric diagnoses predominantly predated dystonia diagnosis, particularly in the 12 months prior to diagnosis (incidence rate ratio [IRR] = 1.98, 95% confidence interval [CI] = 1.9-2.1), with an IRR of 12.4 (95% CI = 11.8-13.1) for anxiety disorders. There was, however, an elevated rate of most psychiatric diagnoses throughout the study period, including the 12 months after dystonia diagnosis (IRR = 1.96, 95% CI = 1.85-2.07).

CONCLUSIONS

This study suggests a bidirectional relationship between psychiatric disorders and dystonia, particularly with mood disorders. Psychiatric and motor symptoms in dystonia may have common aetiological mechanisms, with psychiatric disorders potentially forming prodromal symptoms of idiopathic dystonia.

Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Roles of preoperative anxiety and depression in the outcomes of microvascular decompression in hemifacial spasm for adolescent patients

Hemifacial spasm (HFS) has been recognized as the frequently occurring disease of cranial nerve. At the same time, several articles indicate that, dystonia results in certain psychological disorders. Consequently, this study aimed to examine the association of preoperative depression and anxiety with HFS severity; meanwhile, the role in microvascular decompression (MVD) outcomes after surgery among adolescent patients was also examined.All cases had been classified as two groups based on MVD outcomes among HFS cases; in addition, the preoperative Hamilton anxiety rating scale (HARS) and the Hamilton depression rating scale (HDRS) scores were compared between patients not and still suffering from spasm. Moreover, the multiple logistic regression model was employed in assessing the relationship between preoperative HARS as well as HDRS scores and outcomes of adolescent cases undergoing MVD.The preoperative HARS and HDRS scores showed positive correlation with Cohen spasm grades in HFS patients. Meanwhile, compared with spasm-free group, patients of persistent spams group had apparently higher preoperative HARS and HDRS scores.Our results suggest that, preoperative anxiety and depression status show close association with HFS severity, and they could also impact the MVD outcomes for adolescent cases.

Trust the Patient Not the Doctor: The Determinants of Quality of Life in Cervical Dystonia

Background: Mood disorder is common in cervical dystonia and can impact on quality of life. It often precedes the onset of cervical dystonia and does not improve with botulinum toxin therapy.

Objective: To assess health-related quality of life in relation to mood disorder and measures of severity, disability and pain, in cervical dystonia patients receiving botulinum toxin therapy.

Methods: In a single-center, University Hospital movement disorders clinic, we conducted a comprehensive, cross-sectional study of disease severity, non-motor symptoms, mood and health-related quality of life in patients with cervical dystonia receiving botulinum toxin therapy using TWSTRS-2 for pain, severity and disability; Beck Anxiety Inventory and Beck Depression Inventory. We assessed all variables in relation to health-related quality of life assessed by Cervical Dystonia Impact Profile-58 and the Euro-QoL Utility Index.

Results: In 201 patients (136 women), mean age 61.5 years, significant determinants of impaired health related quality of life were: being a woman, reporting a history of anxiety or depression, prevalent pain, disability, anxiety and/or depression but not physician-assessed disease severity.

Conclusion: Patient-reported measures of pain, disability and, most markedly, mood disorder, are significant factors affecting quality of life; these were totally unrelated to the neurologist-rated measure of disease severity. Mood disorders, the predominant predictor of quality of life, were not addressed in the botulinum toxin clinic.

Mood disorder affects age at onset of adult-onset cervical dystonia

Introduction

Mood disorder is common in cervical dystonia, affects quality of life and may precede the onset of the dystonia. There is controversy as to whether mood disorder is part of the primary process or secondary to the disability.

We assessed the characteristics of cervical dystonia patients in relation to a past history of mood disorder.

Methods

At a University Hospital clinic, in all consenting patients with cervical dystonia, we uniformly collected demographic data, medical history, and prospectively, measures of prevalent mood disorder.

Results

In 193 patients (128 women and 65 men) mean age at onset was 43.9 years and mean duration of cervical dystonia was 17.5 years. Men had earlier age at onset of cervical dystonia than women (p = 0.0037). A history of a mood disorder was reported in 53/128 (41%) women with a significantly earlier median age at onset of cervical dystonia (42 years) than 75/128 (59%) women with no history of mood disorder (48 years) (p = 0.005); 33 (26%) women with mood disorder prior to dystonia also had an earlier age at onset of dystonia than the 75 without such a history (p = 0.0154). A history of mood disorder was more common in women (41%) than men (31%); 54/128 (42%) women and 21/65 (32%) men had current mood disorder symptoms.

Conclusions

In our cervical dystonia clinic population significant differences in the age at onset in women with, and without, a history of mood disorder strongly indicates that anxiety and depression are primary non-motor (and premotor) symptoms of cervical dystonia.

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Sex and mood disorder have independent effects on age at onset of adult-onset cervical dystonia

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Women reporting anxiety and/or depression, had an earlier age at onset of cervical dystonia than women not reporting anxiety and/or depression.

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Anxiety and depression are primary non-motor and premotor symptoms of cervical dystonia.

Mental health outcomes in children with acquired dystonia after basal ganglia stroke and associations with cognitive and motor outcomes

Pediatric arterial ischemic stroke involving the basal ganglia and/or thalamus is one of the most common causes of dystonia in children. Dystonia is a movement disorder in which excessive, involuntary muscle contractions result in twisting or repetitive movements, and abnormal posturing. The basal ganglia have been implicated in mood functioning and difficulties in these domains have been noted in adults with dystonia, yet little is currently known about these outcomes in children with dystonia following stroke. The objective of this study was to explore mental health outcomes in children with basal ganglia stroke and to determine whether children with post-stroke dystonia experience additional mental health difficulties. We also examined associations between mental health, cognitive, and motor outcomes. Participants were 75 children with stroke involving the basal ganglia and/or thalamus (dystonia n = 24, no dystonia n = 51). Results supported the presence of greater levels of anxiety and depression symptoms in children with post-stroke dystonia after stroke relative to those with similar patterns of stroke, but no dystonia. There were no significant associations between motor, cognitive, and mental health outcomes in children with post-stroke dystonia aside from depression and behavioral regulation. Motor and cognitive outcome were significantly associated in the stroke only group. These findings suggest maladaptive reorganization after stroke may contribute to motor, cognitive, and mental health outcomes in children with post-stroke dystonia, and that these outcomes are independent from one another.

Personality Predictors of Yips and Choking Susceptibility

The ability to perform under heightened levels of pressures is one of the largest discriminators of those who achieve success in competition and those who do not. There are several phenomena associated with breakdowns in an athlete's performance in a high-pressure environment, collectively known as paradoxical performances. The two most prevalent and researched forms of paradoxical performance are the yips and choking. The aim of the current study is to investigate a range of psychological traits (fear of negative evaluation, individual differences, anxiety sensitivity, self-consciousness, perfectionistic self-presentation, and perfectionism) and their ability to predict susceptibility to choking and the yips in an experienced athlete sample. 155 athletes (Golfers n = 86; Archers n = 69) completed six trait measures and a self-report measure of yips or choking experience. The prevalence rate for choking and yips in both archers and golfers was 67.7 and 39.4%, respectively. A 2 × 2 × 2 MANOVA and discriminant function analysis revealed that a combination of 11 variables correctly classified 71% of choking and non-choking participants. Furthermore, analysis confirmed that a combination of four variables correctly classified 69% of the yips and non-yips affected participants. In this first study to examine both paradoxical performances simultaneously, these findings revealed that for the yips, all predictors stemmed from social sources (i.e., perfectionistic self-presentation), whereas choking was associated with anxiety and perfectionism, as well as social traits. This important distinction identified here should now be tested to understand the role of these traits as development or consequential factors of choking and the yips.

The Prevalence and Correlation of Non-motor Symptoms in Adult Patients with Idiopathic Focal or Segmental Dystonia

Background

Idiopathic focal dystonia is a motor syndrome associated with dysfunction of basal ganglia circuits. Observations have suggested that many other non-motor symptoms may also be part of the clinical picture. The aim was to assess the prevalence and correlation of non-motor symptoms in patients with common idiopathic focal or segmental dystonia.

Methods

In a single-center cross-sectional case–control study, we evaluated the presence of pain, neuropsychiatric symptoms, and sleep alterations in 28 patients with blepharospasm, 28 patients with cervical dystonia, 24 patients with writer’s cramp, and 80 control subjects matched for sex, age, and schooling. We obtained clinical and demographic data, and evaluated patients using the Fahn–Marsden Dystonia Rating Scale and other specific scales for dystonia. All subjects completed the following questionnaires: Beck Depression Inventory, Beck Anxiety Inventory, Social Phobia Inventory, Apathy Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Brief Pain Scale, and the World Health Organization Quality of Life brief scale.

Results

The patients presented more symptoms of depression, anxiety, and apathy than the control subjects. They also reported worse quality of sleep and more pain complaints. Patients with blepharospasm were the most symptomatic subgroup. The patients had worse quality of life, and the presence of pain and symptoms of apathy and depression were the main influences for these findings, but not the severity of motor symptoms.

Discussion

Patients with dystonia, especially those with blepharospasm, showed higher prevalence of symptoms of depression, anxiety, apathy, worse quality of sleep, and pain. These symptoms had a negative impact on their quality of life.

Randomised controlled trial of escitalopram for cervical dystonia with dystonic jerks/tremor

OBJECTIVE

Trials for additional or alternative treatments for cervical dystonia (CD) are scarce since the introduction of botulinum neurotoxin (BoNT). We performed the first trial to investigate whether dystonic jerks/tremor in patients with CD respond to the selective serotonin reuptake inhibitor (SSRI) escitalopram.

METHODS

In a randomised, double-blind, crossover trial, patients with CD received escitalopram and placebo for 6 weeks. Treatment with BoNT was continued, and scores on rating scales regarding dystonia, psychiatric symptoms and quality of life (QoL) were compared. Primary endpoint was the proportion of patients that improved at least one point on the Clinical Global Impression Scale for jerks/tremor scored by independent physicians with experience in movement disorders.

RESULTS

Fifty-threepatients were included. In the escitalopram period, 14/49 patients (29%) improved on severity of jerks/tremor versus 11/48 patients (23%) in the placebo period (P=0.77). There were no significant differences between baseline and after treatment with escitalopram or placebo on severity of dystonia or jerks/tremor. Psychiatric symptoms and QoL improved significantly in both periods compared with baseline. There were no significant differences between treatment with escitalopram and placebo for dystonia, psychiatric or QoL rating scales. During treatment with escitalopram, patients experienced slightly more adverse events, but no serious adverse events occurred.

CONCLUSION

In this innovative trial, no add-on effect of escitalopram for treatment of CD with jerks was found on motor or psychiatric symptoms. However, we also did not find a reason to withhold patients treatment with SSRIs for depression and anxiety, which are common in dystonia.

TRIAL REGISTRATION NUMBER

NTR2178.

The relationship between the dopaminergic system and depressive symptoms in cervical dystonia

PURPOSE

Cervical dystonia (CD) is associated with tremor/jerks (50%) and psychiatric complaints (17-70%). The dopaminergic system has been implicated in the pathophysiology of CD in animal and imaging studies. Dopamine may be related to the motor as well as non-motor symptoms of CD. CD is associated with reduced striatal dopamine D_2/3 (D2/3) receptor and increased dopamine transporter (DAT) binding. There are differences in the dopamine system between CD patients with and without jerks/tremor and psychiatric symptoms.

METHODS

Patients with CD and healthy controls underwent neurological and psychiatric examinations. Striatal DAT and D2/3 receptor binding were assessed using [¹²³I]FP-CIT and [¹²³I]IBZM SPECT, respectively. The ratio of specific striatal to non-specific binding (binding potential; BP_ND) was the outcome measure.

RESULTS

Twenty-seven patients with CD and 15 matched controls were included. Nineteen percent of patients fulfilled the criteria for a depression. Striatal DAT BP_ND was significantly lower in depressed versus non-depressed CD patients. Higher DAT BP_ND correlated significantly with higher scores on the Unified Myoclonus Rating Scale (UMRS). The striatal D2/3 receptor BP_ND in CD patients showed a trend towards lower binding compared to controls. The D2/3 BP_ND was significantly lower in depressed versus non-depressed CD patients. A significant correlation between DAT and D2/3R BP_ND was found in both in patients and controls.

CONCLUSIONS

Alterations of striatal DAT and D2/3 receptor binding in CD patients are related mainly to depression. DAT BP_ND correlates significantly with scores on the UMRS, suggesting a role for dopamine in the pathophysiology of tremor/jerks in CD.

Sexual Well-Being in Patients with Blepharospasm, Spasmodic Torticollis, and Hemifacial Spasm: A Pilot Study

Mood, anxiety, and other psychological symptoms are common in dystonic patients suffering from blepharospasm (BSP) and spasmodic torticollis (ST). Since sexual well-being is an important aspect of mental health, here, we investigated whether these patients may also experience a worsening of their sexual life. In particular, quality of sexual life was evaluated in patients suffering from BSP (N = 30), ST (N = 30), and in a control group of patient with Hemifacial spasm (HFS; N = 30), undergoing botulinum toxin type A therapy. A group of 30 age-matched healthy volunteers constituted an additional control group. Patients were evaluated just before the periodic injection of botulinum toxin. Sexual functioning was assessed using the Sexual Functioning Inventory, a reduced form of the Golombok Rust Inventory, previously employed in patients with Parkinson's disease. Depression (Beck Depression Inventory) and anxiety (STAI-X1/X2) were also assessed. Results revealed that sexual functioning was significantly affected in patients with BSP, ST, and HFS with respect to healthy controls. Dystonic patients manifested more sexual dysfunction than patients with HFS. Overall, females had a poorer quality of sexual life than males and, among females, women with BSP were the most dysfunctional. Psychological symptoms were present in patients with dystonia, but not in patients with HFS. As discussed in the paper, several factors might be taken into account to explain worse quality of sexual life in patients with dystonia compared to patients with hemifacial spasm. Among them an important role might be played by the central origin of dystonia pathophysiology (i.e., altered activity of cortico-striato-thalamic-cortical circuits). Future investigations are necessary to further explore these preliminary findings, considering that this is the first time that sexual well-being is evaluated in patients with BSP, ST, and HFS, and comparable data are not available.

Bruxism in craniocervical dystonia: a prospective study

AIMS

Bruxism pathophysiology remains unclear, and its occurrence has been poorly investigated in movement disorders. The aim of this study was to compare the frequency of bruxism in patients with craniocervical dystonia vs. normal controls and to determine its associated clinical features.

METHOD

This is a prospective-control study. A total of 114 dystonic subjects (45 facial dystonia, 69 cervical dystonia) and 182 controls were included. Bruxism was diagnosed using a hetero-questionnaire and a clinical examination performed by trained dentists. Occurrence of bruxism was compared between the different study populations. A binomial logistic regression analysis was used to determine which clinical features influenced bruxism occurrence in each population.

RESULTS

The frequency of bruxism was significantly higher in the dystonic group than in normal controls but there was no difference between facial and cervical dystonia. It was also higher in women than in men. Bruxism features were similar between normal controls and dystonic patients except for a higher score of temporomandibular jaw pain in the dystonic group.

DISCUSSION

The higher frequency of bruxism in dystonic patients suggests that bruxism is increased in patients with basal ganglia dysfunction but that its nature does not differ from that seen in bruxers from the normal population.