Management of psychogenic movement disorders (PMD) has received little attention from either neurology or psychiatry communities. When primary care physicians suspect a somatoform disorder, either conversion or somatization (hysteria), or encounter patients with medically unexplained symptoms (1), they rarely initiate therapy. Because of their uncertainty about the diagnosis and because they regard such patients as difficult to manage, they usually refer these patients to specialists. Patients with PMD are usually referred to neurologists who may or may not refer the patients in turn to movement disorder specialists. As general neurologists are becoming more sophisticated in recognizing typical movement disorders, they tend to refer the unusual or atypical ones to specialists in movement disorders. This is one reason why there is an exponential increase in the incidence of PMD in movement disorders centers (2). Because there is no definitive diagnostic test for PMD, the diagnosis must be made by a neurologist skilled in recognizing typical and atypical movement disorders. After the diagnosis is established, it is prudent for the neurologist to consult a psychiatrist, psychologist, psychotherapist, physical or occupational therapist, spiritual leader, or other mental health professional, preferably one experienced in the psychological management of such patients. It is often desirable for the mental health consultant to become involved not only with the patient but also with his or her spouse, companion, parent, or “significant other” to work toward the common goal of returning the patient into the mainstream of life. While a team approach to the management of PMD is essential for optimal results, the responsibilities of the treating physicians must be well-defined. It is imperative that the nonneurologic consultants adequately understand the neurologic diagnosis by detailed briefing from the referring neurologist in order to be able to effectively explicate and reinforce it with the patient and relevant family members. Effective briefing of the mental health consultant by the referring neurologist should avoid inappropriate transmission of perceptions of doubt that will undermine the patient’s confidence in the diagnosis. They should avoid any perceptions of doubt and avoid challenging the diagnosis. There is nothing more disruptive
to the care of patients with PMD than a pronouncement by the consulting psychiatrist or other mental health professional that “there is nothing psychologically wrong with you that can account for the symptoms.”

As there are no published controlled therapeutic trials of PMD, the management of such patients has engendered considerable uncertainty. There is no consensus even among the experts about the best therapeutic approach to patients with PMD. Therefore, the treatment strategies described here are largely based on empirical observations and cumulative personal experience of the authors. When relevant, differences of opinion among the authors will be pointed out.

The treatment of PMD starts with the diagnosis. Many patients with psychogenic disorders have a previous history of other medically unexplained symptoms, and confirmation of prior diagnosis of functional or somatoform disorder may help make the diagnosis of psychogenic disorder (3). The diagnosis, usually made by a neurologist knowledgeable about movement disorders, is based not only on exclusion of organic causes, but also on positive criteria. As described in earlier chapters in this book, these positive criteria include the presence of various clues such as abrupt onset, changing pattern and intensity of the movement, variable frequency, deliberate slowness of movement and speech, verbal gibberish, bizarre movement and gait, excessive startle, and movements that are incongruous with any recognized organic movement disorders. Other features include distractibility, spontaneous remissions, suggestibility, la belle indifférence, embellishment, and manifestations of exhaustion and fatigue (2). In addition, the patient may exhibit other medical or neurologic signs, such as false “give-way” weakness, unexplained paralysis or blindness, false sensory loss, pseudoseizures, and other neurologic symptoms typically associated with hysteria (4). The presence of contractures or the occurrence of the movement disorder during sleep does not exclude the diagnosis of PMD (5). Particularly challenging are those patients who manifest both PMD and an organic disorder (6). Coexistent “organic” neurologic disorder was present in 37% of patients with psychogenic tremor followed for over 3 years (7).

Before the diagnosis is disclosed to the patient, it is critical that the clinician is confident about the diagnosis based on personal evaluation of the patient, and after carefully reviewing all previous medical records, laboratory tests, imaging studies, and history of prior medications and other treatments. Such records may now be more difficult to access in the United States because of the recently enacted Health Insurance Portability and Accountability Act (HIPAA). It is also important to note that under this federal law, patients may now request their own records. Physicians, therefore, must have an open and honest relationship with their patients, and should be certain that their medical records accurately reflect their diagnosis, discussions, and recommendations.

If there is any uncertainty about the diagnosis, it is advisable to admit the patient to the hospital, preferably to the neurology service, to complete the evaluation. However, since insurance carriers and third-party payers often deny hospital admissions for psychiatric diagnoses, the evaluation may need to be completed in an outpatient setting (8). In the United States, using the CPT code 316 (Psychologic factors in physical conditions classified elsewhere) and additional codes to identify the associated condition (e.g., tremor, dystonia, myoclonus, tics, gait disorder) may legitimately facilitate approval for admission and insurance coverage. While it is not considered ideal to inform the patient about the diagnosis at the initial visit, this is sometimes unavoidable, particularly if the patient is allowed only one visit to the specialty clinic. In such cases, we always emphasize to patients that we will be working with their referring physicians to design the most appropriate treatment plan. An experienced clinician learns to read the patient’s body language before making a decision to disclose the diagnosis at the initial visit. We strongly recommend videotaping patients (after signing an informed consent) before disclosing their diagnosis, because their attitude and the nature of the movement disorder may change after they are informed about our impression. Some patients even insist on revoking consent for previous videotape and request that the tape be destroyed.

At least one member of this panel recommends using the term “neuropsychiatric movement disorders” as a preferable term, rather than “psychogenic movement disorders” both for debriefing patients, as well as for general clinical description of this group of disorders. This is not only likely to be more palatable to patients with these disorders, but also effectively conveys a more sophisticated contemporary understanding of the pathophysiology of these disorders.

How the diagnosis is conveyed to the patient may be as important as the actual diagnosis. If presented in a compassionate, supportive, hopeful, nonconfrontational, and professional manner, it is more likely that the patient will react positively, and any potential anger directed against the physician can be diffused and neutralized. When informing the patient about the diagnosis, it is important to emphasize the positive aspects of the diagnosis, specifically that a favorable prognosis is likely, as there is no evidence of any structural neurologic damage or any neurodegenerative disease, such as Parkinson disease. Furthermore, since their disorder is not life-threatening and in fact is potentially completely reversible or resolvable, the patient and family should understand that we are actually conveying the “good news” that this is not a degenerative disease. It is important to indicate that we understand that they are not performing the movements on purpose and that they are not “crazy.” We also emphasize that we recognize the obvious
disability that their movements are causing. Many patients feel that the severity of the symptoms or the resulting disability is quite incompatible with a diagnosis of a psychological cause, and it is important to clarify this misconception.

In our discussion with the patient, we attempt to attribute some of the symptoms to “stress” as this tends to be a more acceptable explanation to patients than a psychiatric diagnosis. Although many patients initially deny any presence of stress, we explain that stress is not always recognized by the patient, but the brain can react to stress in this manner. Once a mutually trusting relationship is established, subsequent interviews with the patients and their family members or friends often identify major stress factors, such as emotional, sexual, or physical abuse, or other stresses at home or at work. To help patients accept the notion of stress-related symptoms, we usually point out that stress is a frequent cause of many physical ailments. Stress may, for example, cause high blood pressure, increased gastric acid production, bowel disturbances, dermatitis, and other physical signs including abnormal movements. We then emphasize that it is up to the patient, preferably with help from a knowledgeable mental health professional, to learn about potential stress factors and to adopt techniques that reduce the effects of stress on the body. At that point, we often recommend that the patient consult a mental health professional knowledgeable in both stress management and the general management of psychogenic movement disorders. In addition to muscle relaxation techniques, such as biofeedback, we often recommend yoga and meditation. We also explain that an active physiotherapy program is usually necessary to retrain the muscles to function normally again, or to desensitize the stress-induced reflexes that produce the abnormal muscle jerks. Also, point out that the patients need to participate in their own care and must work at physiotherapy to get their muscles retrained. These approaches encourage the patients to participate in their own care and empower them to help themselves.