Psychogenic movement disorders in children

A common problem in neurology is the existence of disorders that present with neurologic symptoms but do not have an identifiable neurologic basis. These disorders are often thought to have a psychologic basis. Abnormal movements are among the most frequent symptoms in psychogenic neurologic disorders. Although these disorders have not been studied extensively in children, clinical experience in our busy pediatric movement disorders clinic and many case reports support their existence in this age group. Elements of history, physical examination, and therapeutic intervention must be combined to construct a clear diagnosis of a psychogenic movement disorder. This article reviews the diagnosis and treatment of these disorders and includes two illustrative cases. Review of the current literature reveals a need for prospective trials to provide a solid foundation for better diagnosis and treatment of these disorders.     

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 and organic movement disorders in children

We report on 34 patients with abnormal body movements (AMs; 11 females, 23 males; mean age 10 y 1 mo, range 3 y 6 mo-15 y 11 mo). Twenty-three of the 34 patients had an organic movement disorder (OMD), five patients fulfilled the diagnostic criteria of documented psychogenic movement disorder (PMD), and six patients displayed probable or possible PMD. Diagnosis of children with OMD included essential tremor (n=7), Tourette syndrome (n=5), primary dystonia (n=2), chronic motor tics (n=2), viral cerebellar ataxia (n=2), drug-induced ataxia (n=1), thyrotoxicosis related tremor (n=1), autosomal inherited dystonia (n=1), poststreptococcal chorea (n=1), and benign head tremor (n=1). Consistent findings among patients with PMD included disappearance of AMs when the patients thought they were not being observed and satisfactory recovery from the AMs after psychotherapy or suggestion. Reduction of the movements when the patient was distracted and variability of AMs during full relaxation, sleep, and stress were reported among patients with both PMD and OMD.     

Psychogenic movement disorders in two children.

Two schoolboys with diagnostic criteria for psychogenic movement disorder (PMD) are described: one with bizarre tremor of the right hand and a very slow and cautious gait, another with exaggerated trunk sway and collapses during standing and walking.     

Psychogenic movement disorders

PURPOSE OF REVIEW: This review focuses on recent studies assessing clinical features and laboratory findings that may help diagnose psychogenic movement disorders, and the ongoing controversy about the relationship of these disorders with preceding peripheral injury. RECENT FINDINGS: 'Organic' movement disorders may still be misdiagnosed as psychogenic. Probably more commonly, however, psychogenic movement disorders are underdiagnosed. Most features typically associated with recognized movement disorders, including geste antagoniste or treatment-induced dyskinesias, can be seen in psychogenic movement disorder, and abnormal movements that would not normally be considered psychogenic or produced by psychological factors, such as palatal tremor, may occur on a psychogenic basis. On the other hand, psychiatric features are sometimes seen in neurologically based movement disorders. The diagnostic criteria for psychogenic movement disorders provide a degree of diagnostic certainty based on a combination of clinical and psychiatric features. Laboratory investigations can help exclude specific diagnoses, such as Parkinson's disease with (123I)beta-CIT single photon emission computed tomography, and neurophysiological methods can demonstrate characteristic features of psychogenic movement disorders, such as entrainment or suppression of psychogenic tremor with contralateral hand movements. However, some tests reported to differentiate psychogenic from neurological movement disorders may have incomplete specificity; for example, psychogenic tremor may not always be associated with complete coherence of tremor frequency. An ongoing controversy surrounds movement disorders following peripheral injuries, but recent evidence suggests that such patients should always be screened for the presence of a psychogenic movement disorder. SUMMARY: Psychogenic movement disorder continues to be a difficult diagnosis to make and is likely to be underrecognized. Clinical and laboratory features are emerging, however, that support this diagnosis. The controversy regarding posttraumatic movement disorders continues, but a diagnosis of a psychogenic movement disorder should be actively sought in such patients.     

Psychogenic movement disorders

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

Psychogenic movement disorders

All varieties of movement disorders may be mimicked by a psychogenic disorder, most commonly tremor, dystonia, and myoclonus. Approximately 3% of patients seen in specialty clinics have a psychogenic movement disorder (PMD). The diagnosis of a PMD depends on not just ruling out an organic movement disorder, but moreover, recognizing features from the history and examination that are inconsistent or incongruous with an organic movement disorder. Most PMDs represent a conversion disorder, sometimes as part of a somatoform disorder; less common diagnoses include a factitious disorder or malingering. Co-morbid psychiatric illness is prevalent in patients with PMD including depression, anxiety, and personality disorders. Many PMDs remain chronic, but a multidisciplinary approach centering on psychiatric intervention can be successful. A shorter duration of symptoms and a co-existent treatable psychiatric disorder portend a better prognosis, whereas compensation and pending litigation are associated with a poorer prognosis.     

Psychogenic movement disorders

Diagnosis and treatment of psychogenic movement disorders are challenging for both neurologists and psychiatrists. Symptoms can mimic the full range of organic abnormal involuntary movements, affect gait and speech, or present as unusual undifferentiated movements. Typical clinical characteristics of these disorders are acute onset, fast progression, movement patterns incongruent with organic movement disorders, distractibility, variability, and simultaneous occurrence of various abnormal movements and dysfunctions. Avoidance of iatrogenic damage by unnecessary invasive tests or inappropriate medication, as well as use of appropriate psychiatric treatments are pivotal steps in the management of these disorders. The few clinical trials specific to psychogenic movement disorders focus on antidepressants and psychotherapy. Presence of a comorbid psychiatric diagnosis of depression or an anxiety disorder is a positive prognostic factor, whereas long-standing symptoms, insidious onset of movements, and a psychiatric diagnosis of hypochondriasis, factitious disorder, or malingering are associated with poor outcome.     

Psychogenic movement disorders

Psychogenic movement disorders (PMD) are challenging to diagnose and to treat. Since the nineteenth century, PMDs were recognized and described in painstaking detail. In the modern neurology clinic, PMDs may comprise 2-25% of the patient population. Recognition of the various types of PMDs, differentiation from organic illness and an approach to PMDs are described in this article.     

Psychogenic dyskinesias in patients with organic movement disorders

The association of psychogenic neurological features with organic neurological disease is commonly acknowledged. However, the occurrence of psychogenic dyskinesias in patients with underlying organic movement disorders is not well recognized. Six cases of psychogenic dyskinesias complicating preexisting organic movement disorders are described. This possibility must be carefully considered and excluded before an unusual movement disorder can be considered entirely psychogenic.     

Psychogenic facial movement disorders: Clinical features and associated conditions

The facial phenotype of psychogenic movement disorders has not been fully characterized. Seven tertiary‐referral movement disorders centers using a standardized data collection on a computerized database performed a retrospective chart review of psychogenic movement disorders involving the face. Patients with organic forms of facial dystonia or any medical or neurological disorder known to affect facial muscles were excluded. Sixty‐one patients fulfilled the inclusion criteria for psychogenic facial movement disorders (91.8% females; age: 37.0 ± 11.3 years). Phasic or tonic muscular spasms resembling dystonia were documented in all patients most commonly involving the lips (60.7%), followed by eyelids (50.8%), perinasal region (16.4%), and forehead (9.8%). The most common pattern consisted of tonic, sustained, lateral, and/or downward protrusion of one side of the lower lip with ipsilateral jaw deviation (84.3%). Ipsi‐ or contralateral blepharospasm and excessive platysma contraction occurred in isolation or combined with fixed lip dystonia (60.7%). Spasms were reported as painful in 24.6% of cases. Symptom onset was abrupt in most cases (80.3%), with at least 1 precipitating psychological stress or trauma identified in 57.4%. Associated body regions involved included upper limbs (29.5%), neck (16.4%), lower limbs (16.4%), and trunk (4.9%). There were fluctuations in severity and spontaneous exacerbations and remissions (60%). Prevalent comorbidities included depression (38.0%) and tension headache (26.4%). Fixed jaw and/or lip deviation is a characteristic pattern of psychogenic facial movement disorders, occurring in isolation or in combination with other psychogenic movement disorders or other psychogenic features. © 2012 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     

Drug-induced movement disorders in children

The increased use of stimulants, antipsychotic agents, and antidepressant drugs in children by primary care physicians, psychiatrists, and neurologists has inevitably led to increased numbers of pediatric patients manifesting the side effects of these agents, many of which are movement disorders. Unlike the isolated abnormal involuntary movements associated with drugs prescribed for epilepsy or asthma, movement syndromes (eg, acute dystonic reaction, neuroleptic malignant syndrome, serotonin syndrome, tardive dyskinesia) associated with psychotropic drugs are complex, difficult to recognize, and potentially seriously disabling. Accurate clinical identification of these drug-induced syndromes is critical to engaging the proper therapeutic intervention for them.     

Transient movement disorders in children

Transient movement disorders are quite common in paediatrc practice, occurring mainly in infants. They are underdiagnosed but represent about 20% of cases of movement disorders (tics excluded) seen in a neuropaediatric department. Dystonia, tremor and myoclonus are the most common. Transient idiopathic dystonia of infancy is quite common, and the diagnosis can be suspected on clinical examination. Knowledge of these disorders avoids not only unnecessary tests and treatment, but also familial anxiety. Received: 3 August 1997 Accepted: 2 September 1997     

Familial predictors of treatment outcome in childhood anxiety disorders

OBJECTIVE: To determine whether family factors are predictive of outcome in children with anxiety disorders who are receiving cognitive-behavioral treatment. METHOD: Participants were 61 children aged 8 to 12 years (mean = 10.0, SD = 1.4) with Axis I anxiety disorders who had been referred to a large Toronto children's hospital. Parents and children completed measures assessing family functioning, parenting stress, parental frustration, and parental psychopathology before and after treatment. Outcome measures included clinician-rated functioning (Children's Global Assessment Scale) and self- and parent-rated anxiety (Revised Children's Manifest Anxiety Scale). RESULTS: Child ratings of family dysfunction and frustration predicted clinician-rated improvement (total R2 = 0.28, p < .001). Mother and father reports of family dysfunction, and maternal parenting stress, predicted mother-rated child improvement (total R2 = 0.18, p < .01). Father-rated somatization and child reports of family dysfunction and frustration predicted child-rated improvement (total R2 = 0.25, p < .001). Several family factors improved with treatment. CONCLUSION: Family dysfunction appears to be related to less favorable treatment outcome in children with anxiety disorders.     

Pre-treatment child and family characteristics as predictors of outcome in cognitive behavioural therapy for youth anxiety disorders

Abstract

Background: Cognitive behavioural therapy (CBT) has been found to be effective for children and adolescents (6–18 years) with anxiety disorders, but the non-response rate is high—a fact that may argue for the importance of studies on pre-treatment characteristics of children and their families that predict treatment outcome. Aims: To provide a systematic review of clinical and demographic pre-treatment child and family predictors of treatment outcome in CBT for anxiety disorders in youth. Method: A systematic literature search was conducted based on electronic databases (PsycINFO, Embase and PubMed), and retrieved studies were analysed according to the box-score method of counting significant findings. Results: 24 studies with a sample size ≥ 60 were located. Most studies dealt with the following predictors: child age, gender, comorbidity, symptom severity and parental psychopathology. There was some evidence that a higher degree of pre-treatment symptomatic severity and non-anxiety comorbidity predicted higher end-state severity, but not a lesser degree of improvement. There was some but inconsistent support for a negative influence of parental psychopathology. Conclusion: Studies on pre-treatment child and family predictors of outcome in CBT for youth anxiety disorders have until now resulted in few findings of clinical or theoretical significance.