Single-blind clinical trial of psychotherapy for treatment of psychogenic movement disorders

BACKGROUND: PMD are disabling, but lack any generally accepted treatment strategies. DESIGN/METHODS: Ten patients with PMD received treatment with Psychodynamic Psychotherapy. Patients were assessed with psychiatric rating scales and the movement disorder was rated by a blinded rater with the Psychogenic Movement Disorder Rating Scale (PMDRS). RESULTS: Total mean PMDRS (p = 0.0195), total PMDRS function scores (p = 0.0142), Hamilton depression scores (p = 0.009), Beck anxiety scores (p = 0.002), and GAF (p = 0.0083) all improved with psychotherapeutic intervention. CONCLUSIONS: Psychotherapy and appropriate use of adjunct psychiatric medication can be a successful intervention for PMD.     

Transcutaneous electrical stimulation (TENS) for psychogenic movement disorders

Psychogenic movement disorders (PMDs) often result in disability and diminished quality of life, yet medical therapies are presently limited and largely ineffective. On the basis of previous reports that transcutaneous electrical nerve stimulation (TENS) is helpful for certain patients with organic movement disorders, the authors studied the effects of TENS in 19 patients with PMDs, utilizing the Psychogenic Movement Disorder Rating Scale (PMDRS) as well as patient-rated assessments of PMD magnitude, persistence, and disability. The PMDRS Severity score significantly improved after a mean follow-up of 6.9 months, and short duration of PMD was found to be the only identifiable predictor of a favorable outcome. Although the tingling sensation produced by TENS makes it poorly suited for a controlled clinical trial, the device has a favorable side-effect profile and is an acceptable palliative treatment for a subset of PMD patients.     

Opinions and clinical practices related to diagnosing and managing patients with psychogenic movement disorders: An international survey of movement disorder society members

Five hundred and nineteen members of the Movement Disorder Society completed a 22‐item questionnaire probing diagnostic and management issues in psychogenic movement disorders (PMD). When patients showed definite evidence of PMD with no other unexplained clinical features, approximately 20% said they informed patients of the diagnosis and requested no further neurological testing. The 51% who reported conducting standard neurological investigations to rule out organic causes before presenting the diagnosis to such patients had fewer years of fellowship training and fewer PMD patients seen per month. A non‐PMD diagnosis was correlated with patients' normal social or personal functioning, little or no employment disruption, lack of non‐physiologic findings, and lack of psychiatric history. Ongoing litigation was more predictive of the PMD diagnosis for US compared to non‐US respondents. Two thirds of respondents, more commonly younger and academic clinician researchers, refer PMD patients to a psychiatrist or mental health specialist while also providing personal follow up. Physician reimbursement, insurability of PMD patients, and ongoing litigation interfered with managing PMD patients to a greater extent in the US compared to non‐US countries. Acceptance of the diagnosis by the patient and identification and management of psychological stressors and concurrent psychiatric disorders were considered most important for predicting a favorable prognosis. These findings suggest that expert opinions and practices related to diagnosing and managing PMD patients differ among movement disorders neurologists. Some of the discrepancies may be accounted for by factors such as training, type of practice, volume of patients, and country of practice, but may also reflect absence of practice guidelines. © 2009 Movement Disorder Society     

Psychiatric disorders in adult‐onset focal dystonia: A case‐control study

In a single‐center, case–control study, we investigated the frequency and types of psychiatric disturbances in 89 consecutive patients with various primary focal dystonias (34 had cervical dystonia (CD), 28 blepharospasm (BPS), 16 laryngeal dystonia (LD), and 11 arm dystonia), 62 healthy control subjects and as controls for BPS, 26 patients with hemifacial spasm (HFS). Patients and controls underwent a full psychiatric evaluation. Diagnosis was based on the structured clinical interview for DSM‐IV, obsessive‐compulsive disorder (OCD) was assessed with the Yale‐Brown Obsessive‐Compulsive scale, anxiety with the Hamilton Rating Scale for Anxiety, the severity of depression with the Beck Depression Inventory. Of the 89 patients with focal dystonias studied, 51 patients (57.3%) had a diagnosis of psychiatric disorders compared with only 15 of 62 healthy subjects (24.1%) and 9 of the patients with HFS (34.6%). Depressive disorders were more frequent in the CD and BPS groups than in healthy controls, whereas the frequency of anxiety disorders, OCDs or adjustment disorders approached that of healthy subjects. No difference was found in the frequency of any specific psychiatric disorder in patients with LD and arm dystonia and healthy controls. In 35 of 51 patients who had psychiatric disorders, these started before and in 16 patients after the onset of dystonia. No differences were found in age, dystonia severity, and duration of botulinum toxin treatment between patients with and without psychiatric disturbances. The most common psychiatric features in patients with CD and BPS are depressive disorders. © 2010 Movement Disorder Society     

Psychogenic movement disorders in children

Psychogenic movement disorders (PMDs) are well characterized in adults, but childhood‐onset PMDs have not been extensively studied. We reviewed the medical records of children who were diagnosed in our clinic with PMDs since 1988 and identified 54 patients with PMDs, representing 3.1% of our pediatric movement disorder population and 5.7% of all PMD cases. The mean age at symptom onset was 14.2 years (±2.11, range 7.6–17.7). Similar to published data in adults, two‐thirds of children exhibited multiple PMD phenotypes, the most common being tremor followed by dystonia and myoclonus. Most PMDs were abrupt in onset, paroxysmal and triggered by identifiable physical or psychological trauma. As in adults, childhood PMDs were more likely to affect females, but there was no female predominance in children less than 13 years old. Although prior studies suggest that medically unexplained symptoms beginning in childhood often follow a benign course, this cohort of children experienced marked disability and morbidity related to PMDs, including prolonged school absences and unnecessary surgical procedures in more than one‐fifth of patients. © 2008 Movement Disorder Society     

Psychogenic movement disorders in children: A report of 15 cases and a review of the literature

Data on psychogenic movement disorders (PMD) in children are scarce, with most existing literature relating to adults only. We report 15 cases with the aim of highlighting the clinical characteristics, risk factors, comorbidity, treatment, outcome, and prognosis of PMD in children. Only 13% of cases had onset before age 10, with the mean age at onset being 12.3 years. Females were predominantly affected (F:M = 4:1). The most common types of movement disorders seen were dystonia (47%), tremor (40%), and gait disorders (13%). Multiple hyperkinetic phenomenologies were observed in many cases. Abrupt onset and precipitation by minor injuries, and stressful life events were commonly reported. Clinical clues on examination suggesting a psychogenic origin were similar to those identified in adults. A distinct feature of PMD in children was the predominant involvement of the dominant limb. The underlying psychiatric diagnosis was conversion disorder in the majority of cases. Time from symptom onset until diagnosis of a PMD varied broadly (between 2 weeks and 5 years). Treatment with cognitive and behavioral therapy and rehabilitation by a multidisciplinary team led to improvement in most cases. However, treatment was much more effective in children with a short time from symptom onset to diagnosis and treatment. © 2008 Movement Disorder Society     

Teaching program for the movement disorder society‐sponsored revision of the Unified Parkinson's Disease Rating Scale: (MDS‐UPDRS)

To accompany the newly developed Movement Disorder Society revision of the Unified Parkinson's Disease Rating Scale (MDS‐UPDRS), we developed a teaching program. The DVD‐based program covers the four parts of the scale with visual and verbal instructions for uniform application. For the motor section (Part III), all items except rigidity are shown with an example of each rating option (0–4) as agreed upon by a panel of experts. The rate of agreement for the selected samples was always significant, with Kendall's coefficient of concordance W ranging between 0.99 and 0.72. The teaching program also provides a full patient examination with rating answers provided and four full MDS‐UPDRS cases for a Certificate Program exercise of Part III. This training program is in English, but as non‐English official translations of the MDS‐UPDRS are developed, the program can be potentially modified into different languages. © 2010 Movement Disorder Society     

Nordic walking improves mobility in Parkinson's disease

Nordic walking may improve mobility in Parkinson's disease (PD). Here, we examined whether the beneficial effects persist after the training period. We included 19 PD patients [14 men; mean age 67.0 years (range 58–76); Hoehn and Yahr stage range 1–3] who received a 6‐week Nordic walking exercise program. Outcome was assessed prior to training (T1), immediately after the training period (T2) and—in a subgroup of 9 patients—5 months after training (T3). At T2, we observed a significant improvement in timed 10‐m walking, the timed get‐up‐and‐go‐test (TUG), the 6‐min walking test and quality of life (PDQ‐39). All treatment effects persisted at T3. Compliance was excellent, and there were no adverse effects. These preliminary findings suggest that Nordic walking could provide a safe, effective, and enjoyable way to reduce physical inactivity in PD and to improve the quality of life. A large randomized clinical trial now appears justified. © 2008 Movement Disorder Society     

Teaching program for the Unified Dyskinesia Rating Scale

The Unified Dyskinesia Rating Scale (UDysRS) has been introduced as a comprehensive rating tool for the evaluation of dyskinesias in Parkinson's disease (PD). To enhance a uniform application, we developed a DVD‐based training program with instructions, patient examples, and a certification exercise. For training on the objective assessment of dyskinesia, seventy PD patients spanning the gamut of dyskinesias (none to severe) were videotaped during four tasks of daily living (speaking, drinking from a cup, putting on a coat, and walking). Dyskinesia severity in seven body parts was rated by 20 international movement disorder specialists using the UDysRS for impairment. Each task was also rated for disability. Inter‐rater reliability was assessed with generalized weighted kappa and intraclass correlation coefficients. For the teaching program, examples of each severity level and each body part were selected based on the criterion that they received a uniform rating (± 1 point) by at least 75% of the raters. For the certification exercise, four cases were selected to represent the four quartiles of overall objective UDysRS scores to reflect slight, mild, moderate, and severe dyskinesia. Each selection was based on the highest inter‐rater reliability score for that quartile (minimum kappa or intraclass correlation coefficient = 0.6). UDysRS ranges for certification were calculated based on the 95% confidence interval. The teaching program lasts 41 min, and the certification exercise requires 10 min (total 51 min). This training program, based on visual examples of dyskinesia and anchored in scores generated by movement disorder experts is aimed at increasing homogeneity of ratings among and within raters and centers. Large‐scale multicenter randomized clinical trials of dyskinesia treatment are strengthened by a uniform standard of scale application. © 2009 Movement Disorder Society     

Long-term prognosis of patients with psychogenic movement disorders

Psychogenic movement disorders (PMD) are hyper- or hypokinetic movement disorders associated with underlying psychological or psychiatric disorders. Structured telephone interview was administered to 228 patients with PMD seen in our clinic between 1990 and 2003. The mean age of the subjects was 42.3+/-14.3 years (range 14-70 years), mean duration of symptoms was 4.7+/-8.1 years (range 2-14 years), and mean duration of follow-up was 3.4+/-2.8 years (6 months-12 years). Improvement of symptoms was noted in 56.6% patients; while 22.1% were worse, and 21.3% remained the same at the time of follow-up. In this longitudinal study of patients with PMD we found that indices of strong physical health, positive social life perceptions, patient's perception of effective treatment by the physician, elimination of stressors, and treatment with a specific medication contributed to a favorable outcome.     

Psychogenic tremor: Long term prognosis in patients with electrophysiologically‐confirmed disease

We describe the presenting features and long‐term outcomes of patients with electrophysiologically‐confirmed psychogenic tremor. Clinical information for all patients with psychogenic tremor confirmed by our Movement Disorders Neurophysiology Laboratory (2003–2004) was reviewed. A follow‐up questionnaire was administered to all included patients in 2007. Psychogenic tremor was documented in 62 patients; 33 responded to the questionnaire (53%). Median onset‐age was 50 years (range, 15–71); 23 were female (70%). Clinical certainty of psychogenic etiology was: definite, 8 (24%); probable, 16 (49%), and possible, 9 (27%). Characteristic electrodiagnostic features of psychogenic tremor were documented in all. All but two patients were ultimately given a definite diagnosis of psychogenic tremor; recommended psychiatric consultation was only done by 12 (36%). Twenty‐one patients (64%) rated tremor disability as moderate or severe after a median follow‐up of 5.1 years (range, 3.3–19). Improvement occurred spontaneously in 5 (15%), and after a specific intervention in 4 (12%), whereas 3 (9%) had mild but unchanged symptoms. The mean duration of symptoms, prior to diagnosis with psychogenic tremor, was significantly shorter for patients with mild or no tremor at follow‐up (P = 0.037). Physiologically‐confirmed psychogenic tremor carries a poor prognosis, with unremitting or worse tremor persisting 3‐years after diagnosis in most. © 2008 Movement Disorder Society     

Scales to assess impulsive and compulsive behaviors in Parkinson's disease: Critique and recommendations

Impulse control disorders (ICDs) and related impulsive and compulsive behaviors (together called ICBs) have been increasingly recognized in the context of Parkinson's disease (PD) and treatment. The International Parkinson's and Movement Disorder Society commissioned a task force to assess available clinical screening instruments and rating scales, including their clinimetric properties, make recommendations regarding their utility, and suggest future directions in scale development and validation. The literature was systematically searched for scales measuring a range of reported ICBs in PD. A scale was designated “recommended” if the scale had been employed in PD studies, been used beyond the group that developed it, and had adequate clinimetric data published for PD. Numerous diagnostic screening tools and severity rating scales were identified for a range of ICBs, including compulsive medication use, punding/hobbyism, walkabout, pathological gambling, hypersexuality, compulsive or binge eating, compulsive buying, reckless driving, compulsive exercise, pyromania, trichotillomania, hoarding, kleptomania, intermittent explosive disorder, and internet addiction. For screening across the range of ICBs (except compulsive medication use), the Questionnaire for Impulsive‐Compulsive Disorders in Parkinson's disease (QUIP) and QUIP‐Rating Scale (QUIP‐RS) are recommended, and for severity rating across the range of ICBs the QUIP‐RS and the Ardouin Scale of Behavior in Parkinson's Disease are recommended. The Scale for Outcomes in Parkinson's Disease–Psychiatric Complications is recommended for rating of hypersexuality and the compulsive behaviors gambling/shopping. Further testing of established scales against gold standard diagnostic criteria is urgently required for all other individual ICBs in PD. © 2019 International Parkinson and Movement Disorder Society © 2019 International Parkinson and Movement Disorder Society     

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.     

Clinical characteristics of 49 patients with psychogenic movement disorders in a tertiary clinic in Turkey

Patients admitted to movement disorders outpatient unit at a university hospital between January 2002 and June 2007 were screened for psychogenic movement disorders (PMDs). Out of 1,743 patients, 49 patients (2.8%), including four children, were diagnosed to have PMDs. Women to men ratio was 34/15. The mean age and the age‐at‐onset were 41 ± 17 years and 36 ± 15 years in the adult group, and 10 ± 2 and 9 ± 2 years in children. Among the whole group, 44% had tremor, 24% dystonia, 12% pure gait disorders, 8% parkinsonism, 6% chorea‐ballism, and 4% tic disorder. PMD developed acutely in 85% of patients, and distractibility was observed in 83%. Of the patients, 81% met the criteria for clinically established PMD, whereas 16% for documented and 2% for probable PMD. Although our data was obtained from a different culture, our results showed that hospital‐based frequency and phenomenological features between our PMD group and previously reported ones are similar. © 2009 Movement Disorder Society     

An Update on Psychogenic Movement Disorders

Psychogenic movement disorders (PMD) and other conversion disorders (CD) with apparent neurologic signs (neurologic CD) plague patients and perplex physicians. Due to a lack of objective evidence of underlying brain lesions, CD were largely abandoned by neurologists and remained poorly understood psychiatric diagnoses throughout most of the 20th century. Modern neuroscience now supports increasingly comprehensive biological models for these complex disorders, definitively establishing their place in both neurology and psychiatry. Although it is often clinically useful to distinguish a movement disorder as either “organic” or “psychogenic,” this dichotomy is difficult to defend scientifically. Here we describe the neuroimaging and neurophysiologic evidence for dysfunctional neural networks in PMD, explain the diagnostic potential of clinical neurophysiologic testing, discuss the promising if increasingly complex role of neuropsychiatric genetics, and review current treatment strategies.     

A positive influence of vision on motor symptoms during sensory attention focused exercise for Parkinson's disease

This study evaluated the effect of increased attention to sensory feedback during exercise. Two 12‐week exercise programs that differed only in the presence (PD SAFEx?) or absence (non‐SAFE control group) of increased attention focused on sensory feedback were compared. Participants were assessed symptomatically using the Unified Parkinson's Disease Rating Scale (UPDRS) before the start of the exercise program, immediately following the 12‐week program and after a 6‐week nonexercise washout period. Secondary outcome measures included the Timed‐Up‐and‐Go (TUG), Grooved Pegboard (GP) and velocity and step length of self‐paced gait. Both groups significantly improved on the TUG, GP, velocity, and step length, and this was maintained after a 6‐week washout period. Of additional interest, only the PD SAFEx? program significantly improved motor symptoms (UPDRS). These gains were maintained in the PD SAFEx? group 6 weeks after the exercise was stopped, while motor symptoms significantly worsened in the non‐SAFE group. These results suggest that increasing awareness of sensory feedback may be a critical factor that specifically impacts motor symptoms. Future work should strive to uncover the underlying neurophysiological mechanism behind this effect. © 2009 Movement Disorder Society     

The diagnostic challenge of primary dystonia: Evidence from misdiagnosis

Although the understanding of dystonia has improved in recent years, primary dystonia is still insufficiently recognized and patients may not receive the correct diagnosis, leading to transient or permanent misclassification of their symptoms. We reviewed cases of primary dystonia who were at first misdiagnosed and analyzed the reasons why the correct diagnosis was first missed and later retained. Primary dystonia is misdiagnosed mainly, but not exclusively, in favor of other movement disorders: Parkinson's disease (PD), essential tremor, myoclonus, tics, psychogenic movement disorder (PMD), and even headache or scoliosis. Accounts are more numerous for PD and PMD, where diagnostic tests, such as DAT scan and psychological assessment, support clinical orientation. The correct diagnosis was achieved in all cases following the recognition of inconsistencies in the first judgment and of distinctive clinical features of dystonia. These clues have been collected here and assembled into a diagnostic epitome. © 2010 Movement Disorder Society     

A randomized controlled trial of movement strategies compared with exercise for people with Parkinson's disease

This randomized controlled clinical trial was conducted to compare the effects of movement rehabilitation strategies and exercise therapy in hospitalized patients with idiopathic Parkinson's disease. Participants were randomly assigned to a group that received movement strategy training or musculoskeletal exercises during 2 consecutive weeks of hospitalization. The primary outcome was disability as measured by the Unified Parkinson's Disease Rating Scale, UPDRS (motor and ADL components). Secondary outcomes were balance, walking speed, endurance, and quality of life. Assessments were carried out by blinded testers at baseline, after the 2 weeks of treatment and 3 months after discharge. The movement strategy group showed improvements on several outcome measures from admission to discharge, including the UPDRS, 10 m walk, 2 minute walk, balance, and PDQ39. However, from discharge to follow up there was significant regression in performance on the 2 minute walk and PDQ39. For the exercise group, quality of life improved significantly during inpatient hospitalization and this was retained at follow‐up. Inpatient rehabilitation produces short term reductions in disability and improvements in quality of life in people with Parkinson's disease. © 2008 Movement Disorder Society     

The use of the Simpson Angus Scale for the assessment of movement disorder: A training guide

The Simpson Angus Scale is commonly used for the assessment of Parkinsonian Movement Disorder related to psychiatric drug treatment. The authors present a practical guide to the use of the scale to assist both the learner and the teacher.