IT'S ALL IN YOUR HEAD

Medicine and Health Rhode Island, Feb 2004 by Friedman, Joseph H

I spent three days at an intensive workshop on Psychogenic Movement Disorders. The participants believe that this probably was the first symposium of its kind, which itself would make it interesting.

What are psychogenic movement disorders? That turns out to be a not-soeasy question to answer. Like pornography, we know it when we see it, maybe. Other terms used to describe this are "functional" movement disorders, or "non-physiologic" or "non-organic" movement disorders. These are to be distinguished from factitious disorders and malingering. Malingering refers, of course, to feigned disorders used to seek secondary gain. One of my patients had a "seizure" in my office the day before he was scheduled to go to court. People feign weakness or pain for litigation purposes. Factitious disorders are also feigned, but in a different fashion. Munchausen's syndrome is a factitious disorder. Repeated self-mutilation, injecting bacteria to produce sepsis, inhaling noxious fumes to produce bronchospasm, are factitious disorders. Self-inflicted injury reveals severe underlying psychopathology Conversion disorders, however, are those in which unconscious conflicts or stresses are changed ("converted") into neurological signs.

While this is the stuff of Freud, it turns out that Freud actually lost interest in conversion/hysteria by 1910, and moved on to other topics, although Hollywood seems to have gotten stuck in that earlier time zone. Reading Freud's cases of hysteria is quite instructive for their simplicity. Real-life cases are not as simple as his case reports. One assumes that he lost interest in the topic due to lack of progress, but this is speculative. I have difficulty in diagnosing conversion disorders since the definition requires unconscious motivation even when I can comfortably categorize a disorder as being non-physiologic. How can I possibly determine what is "unconscious?" I can, sometimes, diagnose those disorders which only are "organic" or those which are not. I believe, to a large extent, that doctors diagnose "conversion disorder" if they like the patient, and "malingering" in those they don't like. There is a value judgment that is carried by the terms malingering and conversion.

Psychogenic movement disorders are those that have no basis in the physiology of the motor system and therefore must reside in the realm of the psyche. In various studies it turns out that 25% of new patients seen in movement disorder centers are diagnosed with psychogenic movement disorders. I certainly see about this frequency. They are not rare.

Half of the conference participants were psychiatrists and half were neurologists. Out-of-the-ordinary topics were addressed such as what constitutes consciousness and self-awareness. Questions not covered but of interest include: is catatonia a psychogenic movement disorder? Is the obsessional slowness of severe obsessive compulsive disorder or the Stereotypie movements of schizophrenia conscious or unconscious? What does it mean for a severely psychotic person to "purposely" perform a movement that is out of the ordinary? How is the twisted neck of torticollis different from the twisted neck of a schizophrenic who keeps his head in a peculiar posture to keep the demons from torturing him? How is the stiffness of Parkinson's dis ease different from that of catatonia?

The whole area of dystonia is an engaging example of a disorder which has undergone a sea of changes in how it is viewed. Torticollis and writer's cramp, the two most common forms of focal dystonia, were deemed psychiatric disorders until the 1960s, although dystonia musculorum deformcms was not. It was often inherited and it affected children. Then the dystonias became "neurologic" to the point that one great authority stated that psychogenic dystonia did not exist! Then psychogenic dystonia began to be identified with increasing frequency and recently another esteemed expert stated that the only deforming focal dystonia was psychogenic and that only psychogenic dystonia persisted during sleep! Of course this was an opinion, but it came from the single greatest authority we have. Which means that this is an area in transition and that things aren't always what they seem. Very few members of the audience thought a psychogenic disorder could persist during sleep. But treatment might be with botulinum toxin in one case and psychotherapy in another. Yet the basic question still remains. We think we know what it means when a patient with dystonia or tremor shows complete resolution of the problem when distracted, or is able to perform certain tasks that are clearly incompatible with their alleged movement disorder. But what do we mean when we say that a patient has psychogenic dystonia when it persists during sleep and is so severe that it has deformed a joint to the point of making it useless? Probably we mean that the origin of the problem is emotional and that emotional therapy is the route to a cure, yet few patients will have a clear psychogenic etiology found and fewer yet will respond to psychiatric treatment.