OPINION A role for placebo therapy in psychogenic movement disorders

Center for Ethics, Neuroethics Program, Emory University, 1531 Dickey Drive, Atlanta, GA 30322, USA. .
Nature Reviews Neurology (Impact Factor: 15.36). 04/2013; 9(6). DOI: 10.1038/nrneurol.2013.65
Source: PubMed


Psychogenic movement disorders (PMDs) mimic known movement disorders but are not attributed to an underlying neurological pathology and are generally thought to have a psychological origin. Owing to the lack of a clear pathology, patients often experience multiple referrals, frequent office visits, and numerous-often fruitless-technically sophisticated tests and interventions. No standard of care exists for PMDs, and affected patients can experience debilitating symptoms for a lifetime. Some physicians advocate the use of placebo treatment for patients with PMDs, and placebo therapy can have beneficial neurophysiological effects. Innovative research will be necessary to develop effective therapeutics for psychogenic disorders and to make recommendations for future clinician training and health care policy. This Perspectives article aims to trigger international dialogue focusing on the diagnosis and treatment of patients with PMDs, and to reframe and deepen discussion of placebo prescribing for PMDs and beyond.

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    • "By contrast, the idea of using suggestion under anesthesia, not to talk to the patient, but to demonstrate to the patient the possibility of recovery of a paralyzed, weak or dystonic limb and exclude contractures [12] has received scant attention. Older methods of sedation made this difficult however and only 15 cases of rehabilitation during anesthesia (moving the affected limb) were described in a systematic review of abreaction for conversion disorder since 1920 [3]. "
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    ABSTRACT: Patients with severe functional (psychogenic) neurological symptoms such as paralysis and fixed dystonia present a therapeutic challenge, particularly if no movement is possible during physiotherapy. Sedation has been discussed as a treatment for functional neurological symptoms for 100years but technique, use of video and outcome has not been systematically described. Therapeutic sedation of patients with severe functional neurological symptoms with propofol and follow up at a neuroscience centre. Of eleven patients (median duration 14months), five were cured or had major improvement with sedation. At follow up (median 30months) four were asymptomatic, two were significantly improved and one had minor improvements. We describe a standardized anesthetic and physician technique, refined over consecutive treatments. In carefully chosen patients, therapeutic sedation with propofol can be a useful adjunctive treatment for patients with severe functional neurological symptoms. The treatment deserves randomized evaluation.
    Full-text · Article · Feb 2014 · Journal of psychosomatic research
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    ABSTRACT: Opinion statement: For the treatment of functional motor disorder, we recommend a three-stage approach. Firstly, patients must be assessed and given an unambiguous diagnosis, with an explanation that helps them understand that they have a genuine disorder, with the potential for reversibility. A key ingredient is allowing the patients to describe all of their symptoms as well as their ideas about what may be wrong. The patient should clearly understand that the positive diagnosis is based on the presence of typical signs (e.g., Hoover's sign for paralysis, entrainment test for tremor) that, in and of themselves, indicate the potential for reversibility. We suggest an approach that avoids the assumption that psychological stressors in the patient's life are causing the symptoms. The symptoms themselves are often the main stressor. Insisting that there must be others often leads to a frustrated doctor and an angry patient. Rather, at this initial stage, we encourage exploration of mechanisms - e.g., triggering of symptoms by pain, injury, or dissociation - and a discussion of how symptoms manifest as "abnormal motor programs" in the nervous system.Secondly, further time spent exploring the diagnosis, treating comorbidity, and, in the context of a multidisciplinary team, experimenting with altered movements and behaviors may benefit some patients, without the need for more complex intervention.Thirdly, some patients do require more complex treatment, often with a combination of physical rehabilitation and psychological treatments. Hypnosis, sedation, and transcranial magnetic stimulation may have a role in select patients.Finally, although they have confidence in the diagnosis, many patients do not respond to treatment. Ultimately, however, patients with functional motor disorder may have much greater potential for recovery than health professionals often consider.
    Full-text · Article · Apr 2014 · Current Treatment Options in Neurology
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    ABSTRACT: 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.
    Full-text · Article · Apr 2014
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