Long-term prognosis of patients with psychogenic movement disorders

Introducing Virtual Shared Medical Appointments as a Novel Treatment Platform for Functional Movement Disorders

The landscape of medical care has rapidly evolved with technological advancements, particularly through the widespread adoption of virtual appointments catalyzed by the COVID-19 pandemic. This shift has transcended geographical barriers, enhancing access for underserved populations and those with disabilities to specialized healthcare providers. A notable development stemming from this trend is the emergence of virtual shared medical appointments (VSMAs), which integrate group-based education with telemedicine technology. While VSMAs have demonstrated efficacy in conditions such as obesity, diabetes, and neurological disorders, their effectiveness in managing Functional Movement Disorders (FMD) is currently under investigation. FMDs pose unique challenges in diagnosis and acceptance, with high rates of misdiagnosis and treatment delays. VSMAs offer a promising solution by providing educational modules and fostering peer support among patients with similar diagnoses. At the Cleveland Clinic Center for Neurological Restoration, VSMAs have been embraced to enhance care standards for FMD patients. The program facilitates educational sessions and follow-up meetings to improve treatment adherence and psychological well-being. Early outcomes indicate increased patient acceptance and engagement, with significant program growth observed. Ongoing research aims to evaluate stakeholder perspectives and refine session content to further reduce stigma and the healthcare burden associated with FMDs.

[Functional neurological disorders and forensic medicine: Clinical and practical characteristics]

Functional neurological disorders (FND) have long been a challenge for medicine, both on clinical and psychodynamic point of view. The medico-legal issue is often relegated to the background in medicine, and FND patients also suffer from such neglected topic. Nonetheless, despite the difficulty to properly diagnose FND and the numerous associated organic and/or psychiatric comorbidities, FND patients report a significant level of deficiency and a high alteration of quality of life when compared to other well-recognized chronic disorders such as Parkinson's disease or epilepsy. Whether it is for the estimation of a personal injury, a prejudice, after-effects following a medical accident or certain legal contexts requiring the elimination of a factitious disorder or a simulation, the uncertainty and imprecision in the medico-legal assessment can imply notable consequences on the patient. In this article, we propose to define the different medico-legal contexts in which FND can occur that of the legal expert, that of the consulting physician, that of the so-called recourse physician and finally that of the attending physician who can provide detailed medical files to the patient in order to help him/her in his/her procedures. We then explain how to use standardized objective evaluation tools validated by the learned societies and how to encourage multidisciplinary cross-evaluation. Finally, we specify how to differentiate FND from historically FND-associated disorders (factitious and simulated disorders), through the clinical criteria, considering the difficulties linked to the uncertainty in the clinical examination of these disorders in a medico-legal context. In addition to the rigorous completion of expertise missions, we aim to reduce two damaging consequences characterizing FND: diagnostic delay and the patients' suffering through stigma.

Moving Beyond Movement: Diagnosing Functional Movement Disorder

Functional movement disorder (FMD) is a complex neuropsychiatric syndrome, encompassing abnormal movements and weakness, and is a common cause of potentially disabling neurological symptoms. It is vital to recognize that FMD is a syndrome, with nonmotor manifestations negatively affecting a patient's quality of life. This review highlights a diagnostic algorithm, where a history suggestive of FMD is combined with the presence of positive signs on examination and appropriate investigations to make the diagnosis. Positive signs indicate internal inconsistency such as variability and distractibility, and clinical findings that are incongruent with other known neurological disease. Importantly, the clinical assessment acts as the first opportunity to allow patients to understand FMD as the cause for their symptoms. Accurate and early diagnosis of FMD is necessary given that it is a treatable and potentially reversible cause of disability, with significant risk of iatrogenic harm associated with misdiagnosis.

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

Functional neurological disorders (FNDs) are common but often misdiagnosed.

REVIEW SUMMARY

The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays.

CONCLUSIONS

A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.

The recent surge of functional movement disorders: social distress or greater awareness?

PURPOSE OF REVIEW

To analyze the interrelated factors that have led to the striking increase in functional movement disorders in recent years, with a focus on functional tic-like behaviours (FTLB).

RECENT FINDINGS

The sudden onset of FTLB has been widely observed in several countries since the beginning of the SARS-CoV-2 pandemic, whereas it was previously very rarely reported. Pandemic-related FTLB typically occur in young females, share complex, disabling and tic-lookalike patterns, and are usually triggered by the exposure to videos portraying tic-like behaviours on social media. Both pandemic-related FTLB and prepandemic FTLB are associated with high levels of depression and anxiety. FTLB related to the pandemic highlight the role of social media in the psychopathological behaviours of our time.

SUMMARY

We suggest FTLB are due to a combination of predisposing factors (high genetic and epigenetic risk for anxiety and depression, negative past experiences) and precipitating factors (pandemic and its impact on mental health, exposure to certain social media content). These factors of vulnerability may increase the risk of developing behavioural and emotional problems in youth, such as FTLB. Early diagnosis and appropriate treatment of psychiatric comorbidities seem to be predictors of positive prognosis.

Prognosis of rapid onset functional tic-like behaviors: Prospective follow-up over 6 months

BACKGROUND AND PURPOSE

The prognosis of rapid onset functional tic-like behaviors (FTLBs) is unknown. This prospective cohort study describes the course and treatment of rapid onset FTLBs in adolescents (n = 20) and adults (n = 9) previously reported in two case series.

METHODS

Yale Global Tic Severity Scale (YGTSS) scores were compared between first clinical presentation and 6-month follow-up assessment. All treatments used for FTLBs and any psychiatric comorbidities were recorded.

RESULTS

In adolescents with FTLBs, motor tics, vocal tics, total tics, impairment, and global scores on the YGTSS significantly improved at 6 months, with a mean decrease in the YGTSS global score of 31.9 points, 95% confidence interval (CI) 15.4, 48.4, p = .0005. In adults with FTLBs, only impairment and global scores significantly improved, with a mean decrease in the YGTSS global score of 19.6 points, 95% CI -3.2, 42.3, p = .04. Selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) for anxiety and depression were the most used treatment in both age groups.

CONCLUSIONS

This prospective study suggests that adolescents have a better prognosis than adults with FTLBs. Management of comorbidities with SSRIs and CBT seems effective.

Treatment Approaches for Functional Neurological Disorders in Children

Purpose of Review

Functional neurological disorder (FND) is a multi-network brain disorder that encompasses a broad range of neurological symptoms. FND is common in pediatric practice. It places substantial strains on children, families, and health care systems. Treatment begins at assessment, which requires the following: the medical task of making the diagnosis, the interpersonal task of engaging the child and family so that they feel heard and respected, the communication task of communicating and explaining the diagnosis, and the logistical task of organizing treatment.

Recent Findings

Over the past decade, three treatment approaches—Retraining and Control Therapy (ReACT), other cognitive-behavioral therapies, and multidisciplinary rehabilitation—have been evaluated in the USA, Canada, and Australia. Of children treated in such programs, 63 − 95% showed full resolution of FND symptoms. The common thread across the programs is their biopsychosocial approach—consideration of biological, psychological, relational, and school-related factors that contribute to the child’s clinical presentation.

Summary

Current research strongly supports a biopsychosocial approach to pediatric FND and provides a foundation for a stepped approach to treatment. Stepped care is initially tailored to the needs of the individual child (and family) based on the pattern and severity of FND presentation. The level of care and type of intervention may then be adjusted to consider the child’s response, over time, to treatment or treatment combinations. Future research is needed to confirm effective treatment targets, to inform the development of stepped care, and to improve methodologies that can assess the efficacy of stepped-care interventions.

Clinical and demographic characteristics of patients with functional movement disorders: a consecutive cohort study from a specialized clinic

There is a growing interest in functional movement disorders (FMD). However, epidemiological data from large cohorts of patients with FMD are scarce and come mainly from General Neurology and Movement Disorders Clinics. Recently, specialized FMD clinics have been developed and epidemiological data from such clinics may provide useful information. We aimed to describe the clinical and sociodemographic features of patients diagnosed with FMD at our specialized FMD clinic. A standardized form was used to extract data from electronic records from the first-100 consecutive patients who were evaluated and diagnosed with FMD at our clinic from 2017 to 2019. Mean age was 40.88 ± (14.02) years, 63% females. Most patients were within working-age range, but only 16% were working at the time of consultation. Mean disease duration was 3.74 ± 5.73 years and was longer among men. The most common FMD were gait disturbance (42%), tremor (22%) and dystonia (15%). A precipitating event (mainly physical) was reported by 74%. The onset was mostly acute (83%) and the clinical course fluctuating (62%). Pain (64%) and fatigue (44%) were common comorbidities. Potential joint-hypermobility was present in 21%, mostly women (90%) and related to the presence of dystonia. FMD affects men and women mostly in working-age. Gait disturbance was the most common diagnosis, possibly because it causes a higher level of disability that may lead to consultation in a specialized clinic. Non-motor symptoms (pain and fatigue) were frequent in this cohort. Further data from specialized units may contribute to both understanding and management of FMD.

Identification and initial treatment of involuntary psychogenic movement (conversion) disorder in a 25-year-old male patient

Psychogenic movement disorders present a diagnostically challenging entity that is often frightening for patients. Differentiating movement disorders, providing clear explanations, and addressing underlying conditions with a multidisciplinary approach are essential to successful treatment.

Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments

Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive "laboratory-based" testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes.

Outpatient CBT for Motor Functional Neurological Disorder and Other Neuropsychiatric Conditions: A Retrospective Case Comparison

OBJECTIVE

No gold-standard treatment exists for motor functional neurological disorder (mFND), and limited evidence has been found for the effectiveness of cognitive-behavioral therapy (CBT) in treating the disorder. This study examined sociodemographic and clinical characteristics, treatment outcomes, and treatment dropout among patients with and without mFND who received CBT in a neuropsychiatric outpatient clinic in the United Kingdom.

METHODS

Data from a large anonymized psychiatric register were used to identify patients who received outpatient CBT in a neuropsychiatry clinic between 2006 and 2016 and who had either mFND (N=98) or other neuropsychiatric conditions (ONP) (N=76, control group). The study examined sociodemographic characteristics, physical symptom improvement, and changes in clinical outcome and scores on three instruments measuring psychological distress, psychiatric sequelae of brain injury, and depression.

RESULTS

The most common mFND symptoms were weakness, pain, and tremors. A logistic regression analysis found no sociodemographic differences between patients with mFND who dropped out early and those who completed CBT. Pre- and post-CBT scores on the three instruments were available for only a small subset of patients; both mFND and ONP patients showed significant improvements in overall scores. A logistic regression analysis found only a single predictor of symptom improvement in the mFND group: acceptance of a psychological explanation of symptoms prior to treatment.

CONCLUSIONS

Improvements in physical and psychological functioning were similar for patients with mFND and patients with ONP who were treated in a specialist CBT clinic. This study provides evidence that CBT is feasible and effective for some patients with mFND.

Pediatric Functional Movement Disorders: Experience from a Tertiary Care Centre

Objectives:

Functional movement disorders (FMDs) pose significant diagnostic and management challenges. We aimed to study the socioeconomic and cultural factors, underlying psychopathology and the phenomenology of FMDs in children.

Methods:

The study is a retrospective chart review of 39 children (16 girls and 23 boys) who attended our neurology OPD and the movement disorders clinic at the National Institute of Mental Health and Neurosciences (NIMHANS) between January 2011 and May 2020. The diagnosis of FMD was based on Fahn and Williams criteria and the patients were either diagnosed as “documented” or “clinically established”. All the relevant demographic data including the ethnicity, socioeconomic and cultural background, examination findings, electrophysiological, and other investigations were retrieved from the medical records.

Results:

The mean age at onset was 12.69 ± 3.13 years. Majority of the children were from urban regions (56.41%) and belonging to low socioeconomic status (46.15%). Thirty (76.92%) were found to have a precipitating factor. Myoclonus was the most common phenomenology observed in these patients (30.76%), followed by tremor (20.51%), dystonia (17.94%), and gait abnormality (7.69%). Chorea (5.12%) and tics (2.56%) were uncommon. Tremor (37.5%) and dystonia (18.75%) were more common in girls, whereas myoclonus (39.13%) was more common in boys.

Conclusions:

The symptoms of FMD have great impact on the mental health, social, and academic functioning of children. It is important to identify the precipitating factors and associated psychiatric comorbidities in these children as prompt alleviation of these factors by engaging parents and the child psychiatrist will yield better outcomes.

Invalidation of Parkinson's disease diagnosis after years of follow-up based on clinical, radiological and neurophysiological examination

INTRODUCTION

Diagnosis of Parkinson's disease (PD) is mainly based on clinical features. Accurate neurological examination is required but dopamine transporter (DaT) single photon emission computed tomography (SPECT) could be perfomed to support the diagnosis in ambiguous cases. The aim of this work is to describe the characteristics of patients with a prolonged PD misdiagnosis.

METHODS

We collected data from 24 patients initially diagnosed with PD who had an atypical long-term evolution. We analyzed demographic and clinical characteristics and antiparkinsonian drugs medication. Brain MRI, DaT-SPECT and/or accelerometry/electromyography (EMG) recording were performed in a subgroup of patients. We analyzed the causes of erroneous PD diagnosis as well as the final diagnoses.

RESULTS

Mean age at PD diagnosis was 60.4 ± 14.8 years. Symptoms at onset were rest tremor (n = 19), gait instability (n = 7) and micrographia (n = 4). Mean duration before diagnosis correction was 8.4 ± 5.3 years. All patients were treated by antiparkinsonian drugs with a mean daily levodopa equivalent dose (LED) of 508.1 ± 528.4 mg. All 18 patients who underwent DaT-SPECT had a normal result. The most frequent final diagnoses were essential tremor (n = 11) and functional movement disorders (n = 9).

CONCLUSION

Cases that have been initially diagnosed as PD and then progress in an atypical long-duration fashion may have been misdiagnosed. Absence of genuine bradykinesia, non-sustained response to antiparkinsonian drugs, or absence of levodopa-related side effects should prompt the clinician to reappraise the diagnosis and to consider performing a DaT-SPECT.

The prognosis of functional limb weakness: a 14-year case-control study

Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional limb weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional limb weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of limb weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional limb weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional limb weakness group (1%) and in one neurological control (2%). Eleven patients with functional limb weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional limb weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional limb weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional limb weakness. Misdiagnosis in functional limb weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.

Quality of life in functional movement disorders is as altered as in organic movement disorders

OBJECTIVE

Patients with functional movement disorders (FMD) often report a disability and psychiatric comorbidities. However, few studies have compared these aspects in FMD and in organic movement disorders (OMD). The objectives were to compare QoL and psychiatric comorbidities of FMD and OMD patients.

METHODS

Twenty-one and 30 FMD patients were compared to 21 and 30 sex- and age-matched dystonia and Parkinson patients respectively. QoL was assessed using the Parkinson's Disease Summary Index (PDSI). Psychiatric comorbidities were screened with the Mini International Neuropsychiatric Interview, the Hospital Anxiety and Depression Scale and the Composite International Diagnostic Interview questionnaire.

RESULTS

QoL was more altered in FMD than in dystonia on PDSI (42.1 vs 25.1; p = .003). No significant difference was observed in QoL in FMD and Parkinson's disease on PDSI (38.3 vs 32.2; p = .61). Moreover, FMD patients were more often unemployed because of their condition than dystonia (61.9% vs 14.3%; p = .01) and Parkinson patients (53.3% vs 13.3%; p = .005). The occurrence of anxiety (p = .58 and > 0.99), depression (p = .77 and 0.77), and traumatic events (p = .58 and 0.75) was not different between groups. FMD patients reported more often sexual abuse than dystonia (28,6% vs 4.8%; p = .13) and Parkinson patients (23.3% vs 0.0%; p = .02).

CONCLUSION

FMD patients presented a significant alteration of QoL and no increased psychiatric comorbidities compared to OMD patients. These results highlight the impact of FMD and suggest that neurologists should be as involved in the management of FMD as they are in OMD.

Functional Movement Disorders and Placebo: A Brief Review of the Placebo Effect in Movement Disorders and Ethical Considerations for Placebo Therapy

Background

Functional movement disorders are common and disabling neurologic conditions. Patients with functional neurologic disorders represent a large proportion of neurology clinic referrals, and limited availability of subspecialty care creates a considerable burden for the healthcare system. These conditions are currently treated with a combination of physical therapy and cognitive behavioral therapy, with variable success.

Methods

We searched the Medline database for studies on the epidemiology and physiology of functional movement disorders, as well as those on the placebo effect in movement disorders. We reviewed and summarized the literature on these topics and explored ethical issues concerning the administration of placebos to patients with functional movement disorders.

Results

Studies of placebos, particularly in patients with movement disorders, have shown that these "inert" agents can provide demonstrable neurophysiologic benefits, even in open-label studies. Physician surveys have shown that many administer placebos for diagnostic and therapeutic purposes, although there are ethical concerns about this practice. We used a principle-based approach and reviewed ethical arguments for (justice and beneficence) and against (non-maleficence and autonomy) the use of placebos in functional movement disorders. In this context, we argue for the importance of the therapeutic alliance in preserving patient autonomy while exploring the potential benefits of placebo therapy.

Conclusions

An ethical argument is presented in support of nondeceptive clinical placebo use for the treatment of functional movement disorders. Patient and clinician attitudes regarding the use of placebos should be investigated before placebo-therapy trials are conducted.

Clinical Characteristics of Functional Movement Disorders: A Clinic-based Study

Background

Functional movement disorders are recognized as a “crisis” in neurology. We aimed to determine the rate of incidence of functional movement disorder patients at a university outpatient neurology clinic in South Korea, and highlight the clinical and phenomenological characteristics.

Methods

Patients who were assessed by a movement disorders neurologist at a university hospital between March 2016 and May 2017 were screened for functional movement disorders. Demographic and clinical data were reviewed, and the phenomenology of movements was studied.

Results

Of 321 patients evaluated for the chief complaint of a movement abnormality, approximately 10% (31 patients) were diagnosed with a functional movement disorder. The female to male ratio was 7:1 (27 females to four males). The mean age at presentation was 53 years (standard error 3.6 years), and the mean disease duration was 5 years (standard error 1.4 years). Sixty-one percent (19 out of 31 patients) had a past medical history of depression, anxiety, or other psychiatric illnesses. Tremor and speech abnormalities were most prevalent (19 and 12 patients, respectively). Onset was reported to be abrupt in 14 patients (45%). Thirteen (42%) patients were found to have improvement at a follow-up visit, 10 (32%) had no improvement, and eight (26%) were lost to follow-up.

Discussion

Functional movement disorders are not uncommon in the outpatient neurology clinic. Our results confirm that tremor is the most frequent movement occurring in functional movement disorders, and the most commonly affected body parts were found to be the upper and lower extremities. Speech was also found to be frequently involved (39%). Patients with no improvement at follow-up had longer mean disease duration (6.2 years), consistent with previous observations that prolonged symptom duration is associated with poor clinical outcome. Our study results obtained from a Korean population suggest that previous observations on functional movement disorders from other regions hold true in Eastern Asia.

Secure Attachment and Depression Predict 6-Month Outcome in Motor Functional Neurological Disorders: A Prospective Pilot Study

BACKGROUND

The relationships between baseline neuropsychiatric factors and clinical outcome in patients with functional neurological disorder (FND)/conversion disorder remain poorly understood.

OBJECTIVE

This prospective, naturalistic pilot study investigated links between predisposing vulnerabilities (risk factors) and clinical outcome in patients with motor FND engaged in usual care within a subspecialty FND clinic.

METHODS

Thirty-four patients with motor FND were enrolled and completed baseline and 6-month follow-up psychometric questionnaires. Univariate screening tests followed by multivariate linear regression analyses were used to investigate neuropsychiatric predictors of 6-month clinical outcome in patients with motor FND.

RESULTS

In univariate analyses, baseline secure attachment traits and depression as measured by the Relationship Scales Questionnaire and Beck Depression Inventory-II positively correlated with improved Patient Health Questionnaire-15 scores. In a multivariate linear regression analysis adjusting for the interval time between baseline and follow-up data collection, baseline secure attachment and depression scores independently predicted improvements in Patient Health Questionnaire-15 scores. In additional analyses, patients with a diagnosis of psychogenic nonepileptic seizures compared to individuals with other motor FND subtypes showed a trend toward worse 6-month physical health outcomes as measured by the Short Form Health Survey-36.

CONCLUSION

Future large-scale, multi-site longitudinal studies are needed to comprehensively investigate neuropsychiatric predictors of clinical outcome in patients with motor FND, including functional weakness, functional movement disorders, and psychogenic nonepileptic seizures.

Impact of Transcranial Magnetic Stimulation on Functional Movement Disorders: Cortical Modulation or a Behavioral Effect?

Introduction

Recent studies suggest that repeated transcranial magnetic stimulation (TMS) improves functional movement disorders (FMDs), but the underlying mechanisms are unclear. The objective was to determine whether the beneficial action of TMS in patients with FMDs is due to cortical neuromodulation or rather to a cognitive-behavioral effect.

Method

Consecutive patients with FMDs underwent repeated low-frequency (0.25 Hz) magnetic stimulation over the cortex contralateral to the symptoms or over the spinal roots [root magnetic stimulation (RMS)] homolateral to the symptoms. The patients were randomized into two groups: group 1 received RMS on day 1 and TMS on day 2, while group 2 received the same treatments in reverse order. We blindly assessed the severity of movement disorders before and after each stimulation session.

Results

We studied 33 patients with FMDs (dystonia, tremor, myoclonus, Parkinsonism, or stereotypies). The median symptom duration was 2.9 years. The magnetic stimulation sessions led to a significant improvement (>50%) in 22 patients (66%). We found no difference between TMS and RMS.

Conclusion

We suggest that the therapeutic benefit of TMS in patients with FMDs is due more to a cognitive-behavioral effect than to cortical neuromodulation.

Psychogenic Movement Disorders in Adults and Children: A Clinical and Video Profile of 58 Indian Patients

Background

Psychogenic movement disorders (PMDs) represent 2% to 20% of patients with movement disorders. There is a paucity of literature on PMD in children, with most existing literature relating to adults only.

Methods

For this detailed report of 58 patients (33 adults and 25 children) with PMD, history was assessed in the form of disease onset, duration, precipitating factors, diagnosis, and outcome. Movement phenotype was classified in terms of its appearance as tremor, dystonia, myoclonus, chorea, and others. Clinical evaluations were done to document variability, distractibility, and entrainment. Surface electromyography studies were obtained in patients with tremor.

Results

Seven adults and 7 children were classified with "documented" PMD, and 26 adults and 18 children were classified with "clinically established" PMD. Abrupt onset was common in adults (75.75%) and children (68%). The most common precipitating factors were family and social issues (42.42%) in adults and fear of examination (40%) and school-related issues (24%) in children. Tremor was the most common PMD in both adults and children. The second most common PMD was hemifacial spasm in adults.

Conclusion

The majority of patients had abrupt onset of symptoms, and tremor was the most common form of movement disorder. The second most common PMDs were hemifacial spasm in adults and dystonia and gait abnormality in children. The most common precipitating factors in adults were related to family and social issues; whereas, in children, examination and school-related issues were most common. Complete improvement was seen in only 405 of patients.

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.

Preliminary Evidence for the Treatment of Performance Blocks in Sport: The Efficacy of EMDR With Graded Exposure

Sport psychologists are increasingly confronted with performance problems in sport where athletes suddenly lose the ability to execute automatic movements (Rotheram, Maynard, Thomas, Bawden, & Francis, 2012). Described as performance blocks (Bennett, Hays, Lindsay, Olusoga, & Maynard, 2015), these problems manifest as locked, stuck, and frozen movements and are underpinned by an aggressive anxiety component. This research used both qualitative and quantitative methods in a single case study design to investigate the effectiveness of eye movement desensitization and reprocessing (EMDR) therapy with graded exposure as a treatment method. The participant was a 58-year-old professional male golfer who had been suffering a performance block for 11 years. Specifically, the participant was experiencing involuntary spasms, shaking, muscle tension, and jerking in the lower left forearm while executing a putting stroke. Physical symptoms were coupled with extreme anxiety, panic, and frustration. The study tested the hypothesis that reprocessing related significant life events and attending to dysfunctional emotional symptoms would eliminate the performance block and related symptoms and that the individual would regain his ability to execute the affected skill. Pre-, mid-, and postintervention performance success, using the Impact of Event scale, subjective units of distress (SUD; Wolpe, 1973), and kinematic testing revealed improvements in all associated symptoms in training and competition. These findings suggest that previous life experiences might be associated with the onset of performance blocks and that EMDR with graded exposure might offer an effective treatment method.

Gender and Age Determinants of Psychogenic Movement Disorders: A Clinical Profile of 73 Patients

BACKGROUND

Psychogenic movement disorders (PMD) is a group of disorders that cannot be attributed to any structural or biochemical abnormality, but has an underlying psychiatric illness. The profile of PMD varies according to country and socioeconomic factors.

METHODS

The present study reports the clinical profile of patients with PMD from India. Seventy-three patients with documented or clinically established PMD were seen over a period of 14 years with detailed neurological and psychiatric examinations.

RESULTS

The mean age at presentation was 29.1±15.1 years (women, 51%). Approximately 30% were ≤18 years of age (boys, 63.6%). The onset of symptoms was abrupt in 61.6% and the initial body part most often affected was right upper limb (adults, 29.4%; children, 31.8%). Tremor was observed in 31.4% of adults and 9% of children, whereas myoclonus was more common in children (36.4%). Tremors were more often seen in women (42.3%) than in men (20%), whereas myoclonus was almost equally prevalent in girls (37.5%) and boys (35.7%). Depression was the most common psychiatric comorbidity (men, 16%; women, 15.4%). About 42.5% required hospital admission and 57.5% had significant reduction or complete cessation of PMD after counseling, antidepressants, and/ or placebo.

CONCLUSIONS

PMD was equally prevalent among women and men. Tremor was most often observed in adults, whereas myoclonus was most often observed in children. Electrophysiology and placebo were useful supplementary tools for diagnosing 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.

Prognosis of functional neurologic disorders

The prognosis of functional (psychogenic) neurologic disorders is important in being able to help answer patients' and carers' questions, determine whether treatment is worthwhile, and to find out which factors predict outcome. We reviewed data on prognosis of functional neurologic disorders from two systematic reviews on functional motor disorders and dissociative (nonepileptic) seizures as well as additional studies on functional visual and sensory symptoms. Methodologic problems include heterogeneity in studied samples and outcome measures, diagnostic suspicion and referral bias, small size and retrospective design of available studies, possible treatments during follow-up, and literature review bias. With these caveats, the prognosis of functional neurologic disorders does appear to be generally unfavorable. In most studies, functional motor symptoms and psychogenic nonepileptic attacks remain the same or are worse in the majority of patients at follow-up. Measures of quality of life and working status were often poor at follow-up. Frequency of misdiagnosis at follow-up was as low as other neurologic and psychiatric disorders. Long duration of symptoms was the most distinct negative predictor. Early diagnosis and young age seem to predict good outcome. Emotional disorders and personality disorders were inconsistent predictors. Litigation and state benefits were found to be negative predictors in some studies, but others found they did not influence outcome.

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.

Explanation as treatment for functional neurologic disorders

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.

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.

Multidisciplinary treatment for functional neurological symptoms: a prospective study

Although functional neurological symptoms are often very disabling there is limited information on outcome after treatment. Here we prospectively assessed the short- and long-term efficacy of an inpatient multidisciplinary programme for patients with FNS. We also sought to determine predictors of good outcome by assessing the responsiveness of different scales administered at admission, discharge and follow-up. Sixty-six consecutive patients were included. Assessments at admission, discharge and at 1 year follow-up (55%) included: the Health of the Nation Outcome Scale, the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire-15, the Revised Illness Perception Questionnaire, the Common Neurological Symptom Questionnaire, the Fear Questionnaire and the Canadian Occupational Performance Measure. At discharge and at 1 year follow-up patients were also asked to complete five-point self-rated scales of improvement. There were significant improvements in clinician-rated mental health and functional ability. In addition, patients reported that their levels of mood and anxiety had improved and that they were less bothered by somatic symptoms in general and neurological symptoms in particular. Two-thirds of patients rated their general health such as "better" or "much better" at discharge and this improvement was maintained over the following year. Change in HoNOS score was the only measure that successfully predicted patient-rated improvement. Our data suggest that a specialized multidisciplinary inpatient programme for FNS can provide long-lasting benefits in the majority of patients. Good outcome at discharge was exclusively predicted by improvement in the HoNOS which continued to improve over the 1 year following discharge.

Psychogenic nonepileptic seizures and psychogenic movement disorders: two sides of the same coin?

Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are commonly seen in Neurology practice and are categorized in the DSM-5 as functional neurological disorders/conversion disorders. This review encompasses historical and epidemiological data, clinical aspects, diagnostic criteria, treatment and prognosis of these rather challenging and often neglected patients. As a group they have puzzled generations of neurologists and psychiatrists and in some ways continue to do so, perhaps embodying and justifying the ultimate and necessary link between these specialties.

Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study

BACKGROUND

Gold standard protocols have yet to be established for the treatment of motor conversion disorder (MCD). There is limited evidence to support inpatient, multidisciplinary intervention in chronic, severe cases.

AIMS

To evaluate the characteristics and outcomes of MCD patients admitted to a specialist neuropsychiatric inpatient unit.

METHODS

All patients admitted to the Lishman Unit (years 2007-2011) with a diagnosis of MCD were included. Data relevant to characteristics and status with regard to mobility, activities of daily living (ADLs) and Modified Rankin Scale (MRS) score at admission and discharge were extracted.

RESULTS

Thirty-three cases (78.8% female) were included; the median duration of illness was 48 months. In comparison with brain injury patients admitted to the same unit, more cases had histories of childhood sexual abuse (36.4%, n=12), premorbid non-dissociative mental illness (81.1%, n=27) and employment as a healthcare/social-care worker (45.5%, n=15). Cases showed significant improvements in MRS scores (p<0.001), mobility (p<0.001) and ADL (p=0.002) following inpatient treatment.

CONCLUSIONS

Patients with severe, long-standing MCD can achieve significant improvements in functioning after admission to a neuropsychiatry unit.

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 Phenomenology of Functional (Psychogenic) Dystonia

From the very first descriptions of dystonia, there has been a lack of agreement on the differentiation of organic from functional (psychogenic) dystonia. This lack of agreement has had a significant effect on patients over the years, most particularly in the lack of access to appropriate management, whether for those with organic dystonia diagnosed as having a functional cause or vice versa. However, clinico-genetic advances have led to greater certainty about the phenomenology of organic dystonia and therefore recognition of atypical forms. The diagnosis of functional dystonia rests on recognition of its phenomenology and should not be, as far as possible, a diagnosis of exclusion. Here, we present an overview of the phenomenology of functional dystonia, concentrating on the three main phenotypic presentations: functional cranial dystonia; functional fixed dystonia; and functional paroxysmal dystonia. We hope that this review of phenomenology will aid in the positive diagnosis of functional dystonia and, through this, will lead to more rapid access to appropriate management.

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.

Treatment of functional (psychogenic) movement disorders

Functional (psychogenic) movement disorders are a common source of disability and distress. Despite this, little systematic evidence is available to guide treatment decisions. This situation is likely to have been influenced by the "no man's land" that such patients occupy between neurologists and psychiatrists, often with neither side feeling a clear responsibility or ability to direct management. The aim of this narrative review is to provide an overview of the current state of the evidence regarding management of functional movement disorders. This reveals that there is some evidence to support the use of specific forms of cognitive behavioral therapy and physiotherapy. Such treatments may be facilitated in selected patients with the use of antidepressant medication, and may be more effective for those with severe symptoms when given as part of inpatient multidisciplinary rehabilitation. Other treatments, for example hypnosis and transcranial magnetic stimulation, are of interest, but further evidence is required regarding mechanism of effect and long-term benefit. Though prognosis is poor in general, improvement in symptoms is possible in patients with functional movement disorders, and there is a clear challenge to clinicians and therapists involved in their care to conduct and advocate for high-quality clinical trials.

Imaging psychogenic movement disorders

The neurobiological basis of psychogenic movement disorders (PMDs) has been elusive, and they remain difficult to treat. In the last few years, functional neuroimaging studies have provided insight into their pathophysiology and neural correlates. Here, we review the various methodological approaches that have been used in both clinical and research practice to address neural correlates of functional disorders. We then review the dominant hypotheses generated from the literature on psychogenic paralysis. Overall, these studies emphasize abnormalities in the prefrontal and anterior cingulate cortices. Recently, functional neuroimaging has been used to specifically examine PMDs. These studies have addressed a major point of controversy: whether higher frontal brain areas are directly responsible for inhibiting motor areas or whether they reflect modulation by attentional and/or emotional processes. In addition to elucidating the mechanism and cause, recent work has also explored the lack of agency that characterizes PMDs. We describe the results and implications of the results of these imaging studies and discuss possible interpretations.

Psychogenic paroxysmal movement disorders--clinical features and diagnostic clues

BACKGROUND

The diagnosis of psychogenic paroxysmal movement disorders (PPMD) can be challenging, in particular their distinction from the primary paroxysmal dyskinesias (PxD) remains difficult.

METHODS

Here we present a large series of 26 PPMD cases, describe their characteristics, contrast them with primary PxD and focus on their distinguishing diagnostic features.

RESULTS

Mean age at onset was 38.6 years, i.e. much later than primary PxD. Women were predominantly affected (73%). Most subjects (88.4%) had long attacks, and unlike primary PxD there was a very high within-subject variability for attack phenomenology, duration and frequency. Dystonia was the most common single movement disorder presentation, but 69.2% of the patients had mixed or complex PxD. In 50% of PPMD cases attack triggers could be identified but these were unusual for primary PxD. 42.3% of patients employed unusual strategies to alleviate or stop the attacks. Response to typical medication used for primary PxD was poor. Precipitation of the disorder due to physical or emotional life events and stressors were documented in 57.6% and 65.3% of the cases respectively. Additional interictal psychogenic signs were documented in 34.6% and further medically unexplained somatic symptoms were present in 50% of the cases. 19.2% of patients had a comorbid organic movement disorder and 26.9% had pre-existing psychiatric comorbidities.

CONCLUSION

Although the phenotypic presentation of PPMD can be highly diverse, certain clinical characteristics help in distinguishing this condition from the primary forms of PxD. Recognition is important as multidisciplinary treatment approaches led to significant improvement in most cases.

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.

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.