Psychogenic Movement Disorders and Motor Conversion: A Roadmap for Collaboration Between Neurology and Psychiatry

Human Motor Control Section, Medical Neurology Branch, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892-1428, USA.
Psychosomatics (Impact Factor: 1.86). 03/2011; 52(2):109-16. DOI: 10.1016/j.psym.2010.12.017
Source: PubMed


There are a host of vague terms to describe psychologically-mediated symptoms that mimic neurological disease, such as "functional," "non-organic," "psychogenic," or "medically unexplained." None of these terms has a direct translation in psychiatric classification, and psychiatrists are often faced with patients who do not believe in a psychological origin for their symptoms.
Within the framework of psychogenic movement disorders, we discuss the roadblocks to effective collaboration and treatment in these patients and the current state of the literature regarding diagnosis and treatment.
We describe the approach to these patients from the perspective of neurology and psychiatry, illustrating the differences in terminology and categorization.
Psychogenic movement disorders represent a unique opportunity for these fields to collaborate in the care of a potentially curable but significantly disabling disorder.

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    • "DSM and ICD [4-6] we will consider three issues in the subsequent paragraphs. Furthermore, we will discuss the necessity of a thorough biopsychosocial assessment, which is of particular importance, because these patients are often (not always) reluctant to consider psychosocial aspects related to their complaints by themselves [3]. "
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    ABSTRACT: Background The differential diagnosis of pseudo-neurological symptoms often represents a clinical challenge. The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, made an attempt to improve diagnostic criteria of conversion disorder (functional neurological symptom disorder). Incongruences of the neurological examination, i.e. positive neurological signs, indicate a new approach - whereas psychological factors are not necessary anymore. As the DSM-5 will influence the International Classification of Diseases, ICD-11, this is of importance. In the case presented, a history of psychological distress and adverse childhood experiences coexisted with a true neurological disorder. We discuss the relevance of an interdisciplinary assessment and of operationalized diagnostic criteria. Case presentation A 32-year-old man presented twice with neurological symptoms without obvious pathological organic findings. A conversion disorder was considered early on at the second admission by the neurology team. Sticking to ICD-10, this diagnosis was not supported by a specialist for psychosomatic medicine, due to missing hints of concurrent psychological distress in temporal association with neurological symptoms. Further investigations then revealed a deep vein thrombosis (though D-dimers had been negative), which had probably resulted in a crossed embolus. Conclusion The absence of a clear proof of biological dysfunction underlying neurological symptoms should not lead automatically to the diagnosis of a conversion disorder. In contrast, at least in more complex patients, the work-up should include repeated psychological and neurological assessments in close collaboration. According to ICD-10 positive signs of concurrent psychological distress are required, while DSM-5 emphasizes an incongruity between neurological symptoms and neurophysiological patterns of dysfunction. In the case presented, an extensive medical work-up was initially negative, and neither positive psychological nor positive neurological criteria could be identified. We conclude, that, even in times of more sophisticated operationalization of diagnostic criteria, the interdisciplinary assessment has to be based on an individual evaluation of all neurological and psychosocial findings. Prospective studies of inter-rater reliability and validity of psychological factors and positive neurological signs are needed, as evidence for both is limited. With respect to ICD-11, we suggest that positive neurological as well as psychological signs for functional neurological symptom disorder should be considered to increase diagnostic certainty.
    Full-text · Article · May 2014 · BMC Psychiatry
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    • "malingering or factitious disorders, in which symptoms are attributable to external or internal gains, respectively), such cases are rare [3–5] and most are thought to be due to involuntary processes. PMDs have been described as a “crisis for neurology” [6]: they are very common [7–9], challenging to diagnose [10, 11], difficult to treat effectively [12–15] and associated with a poor prognosis [16–19]. The limited understanding of their psychopathophysiology underlies the difficulties in their management [20, 21]. "
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    ABSTRACT: 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.
    Full-text · Article · Nov 2013 · Current Neurology and Neuroscience Reports
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    • "PMDs are described primarily in the neurology literature, where they are considered to have a psychological origin, and the psychiatry literature, where they are classified as somatoform disorders, most often being conversion.77 Whether tinnitus begets affective disorders and/or affective disorders beget tinnitus, there is a strong comorbid relationship between tinnitus, depression, and anxiety.20 Biological evidence of this association has been elucidated in recent studies demonstrating such neuroanatomic relationships as correlated abnormal primary auditory and limbic function in patients with tinnitus.26,27 "
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    ABSTRACT: THE TERM MIDDLE EAR MYOCLONUS (MEM) HAS BEEN INVOKED TO EXPLAIN SYMPTOMS OF TINNITUS PRESUMABLY CAUSED BY THE DYSFUNCTIONAL MOVEMENT OF EITHER OF THE TWO MUSCLES THAT INSERT IN THE MIDDLE EAR: tensor tympani and stapedius. MEM has been characterized through heterogeneous case reports in the otolaryngology literature, where clinical presentation is variable, phenomenology is scarcely described, the pathogenic muscle is usually not specified, natural history is unknown, and the presumptive definitive treatment, tensor tympani or stapedius tendon lysis, is inconsistently effective. It is not surprising that no unique acoustogenic mechanism or pathophysiologic process has been identified to explain MEM, one of several descriptive diagnoses associated with the complicated disorders of myogenic tinnitus. Here, we explore MEM from the neurologist's perspective. Following the detailed descriptions of two informative cases from our clinic, we systematically evaluate the different mechanisms and movement disorder phenomena that could lead to a diagnosis of MEM. From a functional neuroanatomic perspective, we explain how tensor tympani MEM is best explained as a form of peritubal myogenic tinnitus, similar to the related disorder of essential palatal tremor. From a pathogenic perspective, we discuss how MEM symptomatology may reflect different mechanical and neurologic processes. We emphasize the diagnostic imperative to recognize when myogenic tinnitus is consistent with a psychogenic origin. Both individual patient care and further elucidation of MEM will rely on more detailed clinical characterization as well as multidisciplinary input from neurology, otolaryngology, and dentistry.
    Full-text · Article · May 2013
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