NEUROPSYCHIATRIC ASPECTS OF

MOVEMENT DISORDERS

• DR. D.PHANI BHUSHAN

• DEPARTMENT OF PSYCHIATRY.
MOVEMENT DISORDERS :
A group of neurological conditions in which there is either

• a paucity of voluntary movement in absence of weakness or

spasticity (called akinesia, bradykinesia, hypokinesia) or

• an excess of movement , referred to as abnormal involuntary

movements, dyskinesias, and hyperkinesias.

Abnormal movements are usually caused by muscle contractions,

but they can also be a result of motor inhibitions, as seen in
asterixis, motor impersistence & cataplexy
EVALUATION OF A MOVEMENT DISORDER :

1. Are abnormal involuntary movements present?

• e.g. AIMS vs. gestures, mannerisms, muscle tightness to reduce

pain(guarding), abnormal posture due to arthritis.

NOTE: Psychogenic movements are usually subconscious & thereby

involuntary (somatoform) vs. factitious and malingering, which are
voluntary.
 EVALUATION OF A MOVEMENT DISORDER
2.) What is the nature of involuntary movement?

• Evaluate features such as body parts involved; Rhythmicity;

speed; duration;
• Pattern repetitive, flowing, continual, complex vs. simple;
Suppressible: Volitional, sensory tricks, by
distraction;accompanied by sensations such as an urge or
restlessness; presence during sleep

3.)What is the cause of movements?

4.)Treatments: specific vs. symtomatic

LIST OF MOVEMENT DISORDERS
I . HYPOKINESIAS

• Akinesia/ bradykinesis(parkinsonism)
• Apraxia
• Blocking ( holding)tics
• Cataplexy( Psychomotor depression, obsessional slowness)
• Freezing phenomenon
• Hesitant gaits
• Hypothyroid slowness
• Rigidity
• Stiff muscles
LIST OF MOVEMENT DISORDERS
II . HYPERKINESIAS :

• Abnormal dyskinesias • Jumpy stumps

• Akathetic movements • Moving toes/fingers
• Asynergia/ ataxia • Myoclonus
• Athetosis • Myokymia
• Ballism • Myorhythmia
• Chorea • Paroxysmal dyskinesias
• Dysmetria • Restless legs
• Dystonia • Stereotypies
• Hemifacial spasm • Tics
• Hyperekplexia • Tremors
• Hypogenic dyskinesia
Notice that psychogenic movements are not
on this list
• PMD is a condition/disorder and not a phenomenology.

• PMD would be analogous to Wilson disease or Huntington disease.

• They are not on the list either. All three refer to an etiology( all 3
have a variety of phenomenologies)
 RECOGNIZING THE DYSKINESIAS

Level A: Immediate Impressions

1. Rhythmic vs Arrhythmic
2. Sustained vs Non sustained
3. Paroxysmal vs Continual vs Continuous
4. Sleep vs Awake

Level B: More prolonged observations

1. At rest vs With action vs Overflow

2. Patterned vs Non- patterned
3. Combinations of variety of movements
Level C: Requiring Longer Observations

1. Speed: slow vs fast

2. Amplitude: ballistic vs not ballistic
3. Force: powerful vs easy to overcome
4. Suppressibility
5. Vocalizations
6. Self mutation
7. Complexity of movements
8. Sensory component
9. Occular movements
RHYTHMIC vs ARRHYTHMIC MOVEMENTS
RHYTHMIC vs IRREGULAR vs ARRHYTHMIC
Tremor Cortical myoclonus Akathetic movements
resting Minipolymyoclonus Athetosis
postural Dystonic tremors Ballism
action Chorea
intention Dystonia
Orthostatic tremor Hemifacial spasm
Dystonic tremor Hyperekplexia
Dystonic myorhythmia Arrhythmicmyoclonus
Myoclonus, segmental Stereotypy
Epilepsia partialis continua Tics
Myoclonus, oscillatory
Moving toes/ fingers
Myorhythmia
Periodic movements in sleep
Stereotypies
Tardive dyskinesia
SUSTAINED vs NON –SUSTAINED

Stiff person
Rigidity
Dystonia All Others
Oculogyric crisis
Paroxysmal dystonia
Dystonic tics
Sandifer syndrome
Neuromyotonia
Congenital torticollis
Orthopedic torticollis
PAROXYSMAL vs CONTINUAL vs CONTINUOUS

Tics Ballism Abdominal dyskinesia

PKD Chorea Athetosis
PNKD Dystonic movmnt Tremor
PED Myoclonus, Dystonic postures
Episodic ataxia arrhythmic Minipolyclonus
Paroxysmal tremor Some stereotypies Myoclonus, rhythmic
Hypogenic dystonia Some akatehtic Tardive stereotypy
Stereotypies movements Myokynia
Akathetic movements Tic status
Restless legs Jumpy stumps
Moving toes
Myorhythmia
Akathitic moaning
APPEARS ONLY PERSISTS DURING DIMINISHES DURING
DURING SLLEP SLEEP SLEEP

Hypogenic Secondary palatal myoclonus Primary

dyskinesia Ocular myoclonus palatal
Spinal myoclonus myoclonus
Periodic movements Oculofaciomasticatory
in sleep myorhythmia
Severe tics

Peripheral Mov Disorder

Moving toes
Myokymia
Neuromyotonia
(Isaacs syndrome)
AT REST ONLY ( disappears with action)
Akathetic movements Restless legs
Paradoxical dystonia Orthostatic tremor
Resting tremors ( only on standing)

WITH ACTION ONLY

Ataxia; Tremor: postural, action, intention
Action dystonia, myoclonus, Task-specific tremor , DYSTONIA

AT REST & CONTINUS WITH ACTION

Abdominal dyskinesia, Athetosis, Ballism, Chorea
Dystonia at rest, Jumpy stumps, Minipolymyoclonus
Moving toes/ fingers, Myoclonus at rest, Myokymia
Pseudodystonias, tics
PATTERNED NON- PATTERNED
abdominal dyskinesias all others
dystonia
hemifacial spasm
moving toes/fingers
segmental myoclonus
myorhythmia
myokymia
tardive stereotypy
tremor
COMBINATION OF VARIETIES OF MOVEMENTS
• Psychogenic movements
• Tardive syndromes
• Wilson’s disease
• Huntington disease
• Neuroacanthocytosis
• Some dystonias (e.g parkinsonism, myoclonus)
• Neurodegenerations with brain iron accumulation
• Some spinocerebellar ataxias
• Dentatorubral- pallidoluysian atrophy(DRPLA)
 SPEED : FAST vs SLOW

FASTEST INTERMEDIATE SLOWEST

Minipolymyoclonus chorea athetosis

Myoclonus ballism moving toes
Hyperkplexia jumpy stumps myorhythmia
Hemifacial spasm tremors akathetic
tardive stereotypy movements
• AMPLITUDE
• BALLISTIC vs NON- BALLISTIC
• Ballism chorea & all others

• Jumpy stumps would be ballistic but a short stump

• keeps the amplitude relatively small
• Very small amplitude ; minipolymyoclonus

• FORCE
• POWERFUL vs EASY –TO- OVERCOME
• Stiff person > dystonia > all others
• Jumpy stumps
SUPPRESSIBILITY:
Stereotypies > tics , akathetic movements> chorea>
Ballism> dystonia> tremor

Not suppressible: hemifacial spasm, myoclonus,

minipolymyoclonus, hyperkplexia, myorhythmia, moving
toes

VOCALIZATIONS:
Phonic tics
Akathitic moaning
Huntington disease
Neuroacanthocytosis
Cranial dystonia
• SELF-MUTILATION:
• Lesch-nyhan syndrome, neuroacanthocytosis, Tourette syndrome,
• Psychogenic movement disorders

• COMPLEX MOVEMENTS:
• Tics, akathitic movements, compulsions, stereotypies,
• Psychogenic movements ( NOTE: each of the above also consist
• of simple movements)

• SENSORY COMPONENT:
• Akathisia, moving toes/ fingers, restless legs, tics
OCULAR MOVEMENTS:
 Ocular tics
 Oculogyric crisis
 Opsoclonus
 Ocular myoclonus
 Ocular myorhythmia
 Ocular dysmetria
 Nystagmus
 Square wave jerks
FIRST PRINCIPLES
• Movement arises from contraction of muscle

• Muscles are under the control of alpha- motorneurons

INVOLUNTARY MOVEMENTS ARISING FROM
NEUROMUSCULAR CONDITIONS :-
• Muscle
- Schwartz Jampel syndrome
• Alpha motor neuron axon
- hemifacial spasm
-peripheral myoclonus
-fasciculation
-neuromyotonia
• Anterior horn cell
-fasciculation
- spinal alpha rigidity
SEGMENTAL INFLUENCES ON THE ALPHA
MOTONEURON
•SPINAL SEGMENT
MOVEMENT DISODERS ARISING FROM SEGMENTAL DYSFUNCTION

DISORDER MECHANISM

Tetanus Tetanus toxin blocks the release of GABA

and glycine at spinal synapses

Stiff person syndrome Mainly a disorder of GABA and

presynaptic inhibition in the spinal cord

Heriditary hyperekplexia A disorder of glycine receptors with

deficient inhibition at mulltiple synapses
including that from the inhibitory
interneuron
SUPRASEGMENTAL INFLUENCES ON THE
ALPHA MOTONEURON
INJURY TO CORTICOSPINAL TRACT

• “ upper motor neuron syndrome”

• spasticity
SUB CORTICAL INFLUENCES ON THE PRIMARY
MOTOR CORTEX
SUB CORTICAL INFLUENCES

Cerebral
cortex i.e.
via thalamus
motor via thalamus

via pons
Basal ganglia Cerebellum

Motor neurons &

interneurons
 cortex

Striatum Striatum
D2 D1 Thalamus
Hyperdirect Indirect

Direct
STN GPe
Facilitation

GPi Inhibition

A center- surround organisation of Gpi output can sharpen the

motor command
BASAL GANGLIA DISORDERS

• Hypokinetic , too little movement

- Parkinson’s disease
• Hyperkinetic , too much movement
- Dystonia
-Choresa, dyskinesia
FUNDAMENTAL DISTURBANCES OF
bradykinesia in Parkinson’s disease :
• Insufficient energy for movement
-both for movement initiation and execution
-greater difficulty with more complex movement
-fatigue
• Insufficient scaling
• Particular difficulty with internal versus external triggering
FUNDAMENTAL PROBLEM IN PD

• Reduction in facilitation of movement in both

direct and indirect pathways.

• Bradykinesia is the main result.

• Bradykinesia correlates well with the dopamine deficiency

and is the most responsive to dopamine replacement
Dystonia Pathophysiology

• Defective inhibition.

• Specifically, defective “center-surround” inhibition

Fundamental problem of dystonia

• Imbalance of excitation and inhibition with reduction of inhibition.

• One main type of deficient inhibition is surround inhibition

The Basal Ganglia

• A fundamental action is to aid in the process of muscle selection and

inhibition, including scaling of magnitude, particularly when
movement is initiated internally
• Disorders will lead to reduced movement or overflow and involuntary
movement
What is dopamine doing in the BG?

• Facilitates movement

• Signals reward

-relevant for motor learning

-relevant for motivating behaviour

-pathological relevance here for drug addiction and

dopamine dysregulation syndrome
Physiology of ataxia

• Dysmetria

• Dyssynergia( decomposition of movement)

• Dysrhythmia

• Dysdiadochokinesia

• Tremor

• Impaired motor learning

-particularly adaptation learning

The Cerebellum

• Important role in the timing of movement

• Error corrections and adjustments to movement

• Adaptation learning
CORTICAL INFLUENCES ON THE PRIMARY
MOTOR CORTEX
 Praxis

Ability to perform skilled/ learned movements

Apraxia

• Inability to perform praxis movements

• The problem cannot be ascribed to a language

comprehension disorder or elemental sensorimotor deficit,
including ataxia & bradykinesia
MOTOR APRAXIAS :

Loss of hand and finger dexterity;

LIMB KINETIC APRAXIA significantly affecting manipulative
movements

Deficit in pantomiming tool use and

IDEOMOTOR APRAXIA LINgestures with temporal and spatial
errors .Knowledge of tasks is still
present

Failure to carry out a series of tasks

IDEATIONAL APRAXIA using multiple objects for an intended
purpose; problem in the sequencing of
actions. Tools are identifiable
Movement disorders with confusion about
voluntariness

• Tics: often said to be voluntary but patients cannot make

them

• Chorea: early in the illness patients do not recognizetheir

involuntary movements as being involuntary

• Alien hand phenomenon: unwanted movements arise

without sense of their being willed, with associated difficulty
in self initiated movement
• Psychogenic movements: look voluntary but said to be

involuntary

• Schizophrenia: look normal and goal directed, but the

patient may think that they are being externally controlled

Conclusions about the motor system

• While movement is produced by muscle, the control signals come

from the entire CNS as influenced by external stimuli, internal drives
and emotions.

• Voluntary movement can be distorted in many ways depending on

site of disorder.

• Involuntary movements are produced in different areas of the brain,

but not “interpreted” as voluntary( but we don’t know why)
NEUROTRANSMITTERS:

• Dopamine
• Acetylcholine
• Glutamate
• GABA
• Norepinephrine
• Serotonin
• adenosine
 Acetylcholine

• Two neuron types

-The “giant aspiny interneuron” of the striatum

- A projection neuron arising in the PPN

• ACh receptors:

-Nicotinic: ionotropic

-Muscarinic: metabotropic, G-protein coupled

Glutamate

• Primary excitatory neurotransmitter

• Receptors
-Metabotropic ( 3 classes)
Group 1, 11, 111 depending on mGluR composition
-Ionotropic ( 3 classes)
NMDA
Kainate
AMPA
GABA

• Primary inhibitory neurotransmitter

• Receptors
- GABA-A ( &GABA-C): Ionotropic
Open chloride & potassium channels
Benzodiazepine sensitive or not
- GABA-B : Metabotropic
Open potassium & inhibit calcium channels
G protein coupled
Adenosine

• Critical molecule in energy metabolism

• Plays a role as a neurotransmitter
• A2A receptors in basal ganglia, often coupled with the D2 receptor
postsynaptically
-adenosine will reduce dopamine binding
-adenosine antagonists (like caffeine) will increase dopamine
binding
STRIATUM

• Caudate, putamen, ventral striatum

• Cells
- 80-95% medium spiny neurons(projection)
GABAergic
Those with D1 receptors also have the protein neurotransmitters
substance P and dynorphin
Those with D2 receptors also have the protein neurotransmitter
enkephalin
Globus Pallidus

• GPi and Gpe ; dorsal and ventral

• SNr similar to the Gpi

• Most neurons are large, parvalbumin positive, GABAergic

neurons with large dendritic arbors

• Only few interneurons

Subthalamic Nucleus

• Most neurons are glutamatergic with long dendrites

• 7.5% neurons are GABAergic interneurons

Substantia Nigra (compacta)

• Dopaminergic neurons

• Note strong inhibitory influence from the lateral habenula

Pedunculopontine Nucleus

• Compacta (PPNc)
- cholinergic
• Dissipatus (PPNd)
-glutamergic with some cholinergic
• Other nuclei in the viscinity
- midbrain extrapyramidal area
- peripeduncular nucleus
- sub cuneiform nucleus
What do the BG do????

• Movement selection (self selection)

• Movement preparation
• Scaling of movement
• Terminating an ongoing motor program
• Switching movements/sequential movement
• Automatic running of motor programs
• Motor learning, operant conditioning
• reward, that facilitates decision making and learning(habits might
result)
Do we need the BG ?

• After pallidectomy, patients with PD do reasonably well

• Hence, the BG to some extent must be a parallel pathway of

brain function
TERMINOLOGIES THAT HAS BEEN USED
TO DESCRIBE THIS CONDITION
• Psychogenic ---------> Conversion disorder
• Functional --------- > Somatoform disorder
• Non-organic --------- > Somatization disorder
• Hysteria ---------> Factitious disorder
• Medically ---------> Malingering
unexplained illness
TERMINOLOGY

• Psychogenic = non-organic vs organic

• Functional

• Non-organic

• Hysteria

• Medically unexplained illness

PSYCHOGENIC vs FUNCTIONAL

• Functional is often used by physicians who

hesitate to tell their patients their disorder
is psychiatrically based.
• Functional is an ambiguous term. In the past
it was used to refer to organic neurologic
diseases in which pathology was unknown.
• Psychogenic has the major advantage of being
the etiologic basis of symtoms.
• It is analogous to the way we label other
medical disorders – by etiology eg. post-traumatic epilepsy,post
encephalitic parkinsonism,drug induced parkinsonism,
pneumococcal pneumonia.
Some Useful Signs To Help In The
Dx of Psychogenic Cases
• Motor signs
-Hoover sign
-Give way weakness
-Knee buckling
-Inverted foot dragging
-Antagonist contraction
-Arm drop
-Sternocleidomastoid weakness
• Sensory/Behavioral disturbances
-Midline splitting
-La belle indifference
MISDIAGNOSIS
WHICH IS WORSE FOR THE PATIENT ?

• Being misdiagnosed as psychogenic when the patient has an organic

disease.

• Being misdiagnosed as having an organic disorder when the patient has

a psychogenic one.

• Having such a diagnosis reinforces to the patient that s/he has an

organic disease, which makes it harder to convince her/him otherwise ,
& perpetuates incorrect treatment & delays applying appropriate
therapy.
Reports on the misdiagnosis of organic
dystonia as being psychogenic :
INVESTIGATIONS MISDIAGNOSED

Eldridge et al., 1969 23/44 (52%)

Marsden and Harrison ,1974 18/42 (43%)

Cooper et al., 1976 56/226 (25%)

Lesser and Fahn, 1978 37/84 (44%)

Degree of certainty of the diagnosis of a
Psychogenic movement disorder

• Documented psychogenic movement disorder.

• Clinically established psychogenic movement disorder.

• Probable psychogenic movement disorder.

• Possible psychogenic movement disorder.

Definitions For Psychogenic Movement Disorders

• DOCUMENTED

• Relief of intractable symptoms by:

• Placebo
• Psychotherapy
• Physiotherapy
• Psychological suggestion
• Being left alone unobserved
• Surveillance video monitoring
• Not acceptable without above:
Improvement with hypnosis
Improvement with amobarbital
Pt is suspected of having a psychogenic etiology, but
relief not obtained.
DEFINITIONS FOR PSYCHOGENIC
MOVEMENT DISORDERS
• Clinically Established
At least 2 of the following, one being #1 or #2
Inconsistent over time
Incongruent with a known movement disorder
Signs of give-way weakness, false sensory findings, or self-inflicted
injuries
Multiple somatizations
Obvious psychiatric disturbance present
 Deliberate slowness or excessive fatigue
Movement disorder disappears with distraction
Electrophysiologic analysis of the phenomenology of myoclonus,
tremor or startle that does not fit with the organic pattern of these
phenomenologies.
PSYCHOGENIC vs PSYCHIATRIC DISORDERS

• Movement associated with psychosis & other psychiatric

conditions are not necessarily psychogenic movement
disorders.

• When the motor phenomenology is a common feature of a

psychiatric condition, it should be considered a psychogenic
movement disorder.
NON-PSYCHOGENIC MOVEMENT DISORDERS
ASSOCIATED WITH PSYCHIATRIC DISORDERS
• Movement disorder Psychiatric disorder
• Psychomotor slowness Depression
• Obsessional slowness OCD
• Compulsive movements OCD
• Catatonic immobility Schizophrenia,
depression
• Stereotypes OCD, Autism,
Schizophrenia
• Fear of falling gait Anxiety, Agoraphobia
disorder
• NEVER HAVING SEEN A MOVEMENT DISORDER RESEMBLING THE
PATIENTS IS NOT SUFFICIENT TO MAKE A DIAGNOSIS OF A
PSYCHOGENIC DISORDER.

• IMPORTANT TO FIND A POSITIVE FINDING ON EXAMINATION.

CLASSIFICATION BY PSYCHIATRISTS OF
PSYCHOGENIC DISORDERS
• Somatoform Disorders
• Factitious Disorders
• Malingering
(vs Organic Disorders)
DEFINITION OF PSYCHIATRIC TERMINOLOGY
(DSM- V)

• Somatoform Disorders

Physical symptoms linked to psychological factors (subconscious)

1. Conversion disorders due to expression of psychological conflict

or need.

2. Somatization disorders (hysteria, Briquet’s syndrome):

recurrent multiple somatic complaints of several years duration,
beginning before the age of 30.
DEFINITION OF PSYCHIATRIC TERMINOLOGY (DSM-V)

• Factitious Disorder

Physical symptoms intentionally produced, hence under

voluntary control, due to psychological need; includes
Munchausen syndrome. Due to a mental disorder.

Generally associated with severe dependent, masochistic

or antisocial personality disorders.
DEFINITION OF PSYCHIATRIC TERMINOLOGY(DSM-V)

• Malingering

 Voluntarily produced psychical symptoms in pursuit of a

goal such as financial compensation, avoidance of school or
work, evasion of criminal prosecution, or acquisition of
drugs.

Malingering is not considered to be a mental disorder.

CLUES SUGGESTING PSYCHOGENIC MOVEMENT DISORDERS

• Clues relating to the movements

1. Abrupt onset

2. Inconsistent movements (changing characteristics over time)

3. Incongruous movements and postures

(movements don’t fit with recognised disease patterns or with

normal physiological patterns)
4. Presence of certain types of abnormal movements that are

fairly common among individuals with psychogenic movement

disorder, such as :

- rhythmic shaking

- bizarre gait, knee buckling gait

- deliberate slowness carrying out requested voluntary

movements
 - abnormal speech pattern: hesitancy, bursts of verbal
gibberish; changing dialects & accents.

- exaggerated mvts when arising from a chair or in response

to the pull test
5 . Presence of additional types of abnormal movements that are
not known to be part of the primary or principal movement
disorder pattern that the patient manifests.

That is , a combination of movements that ordinarily do not go

together (relates to incongruous mvts)
6. Manifesting exhaustion, excessive fatigue
7. Delayed , often excessive , startle response to a stimulus
8. Spontaneous remissions
9. Movements disappear with distraction
10. Tremors disappear when handling treasured objects
11. Entrainment of tremor to rate of rapid successive mvts
12. Response to placebo, suggestion or psychotherapy
13. Manifests as a paroxysmal disorder
14. Side to side mouth movements
15. Dystonia beginning as a fixed posture
16. Fixed contractures
COMBINATIONS OF VARIETIES OF
MOVEMENTS :

• Psychogenic movements

• Tardive syndromes

• Wilson disease

• Huntington disease

• Neuroacanthocytosis
• Neurodegenerations with brain iron accumulation

• Some dystonias (e.g. parkinsonism , myoclonus) .

• Some spinocerebellar ataxias ,esp. SCA – 3 , Friedreich

• Dentatorubral – pallidoluysian atrophy (DRPLA)

OTHER MEDICAL OBSERVATIONS :

1. False ( give – way ) weakness

2. False sensory complaints ( e.g. hyperpathia to touch but not to

clothes touching the skin)

3. Multiple somatizations or undiagnosed conditions

4. Self inflicted injuries

5. Obvious psychiatric disturbances

6. Employed in the health profession or in insurance claims

7. Benefit of secondary gain , including continuing care by a “devoted “

spouse.

8. Litigation or compensation pending

 FIXED POSTURES
1. Fixed postures are sustained postures that resist passive
movement and do not change with a change in body position.
If due to organic dystonia, this could indicate the presence of
contractures
2. The presence of such fixed postures are highly likely to be due
to a psychogenic dystonia.
3. Fixed postures following focal trauma is often called reflex
sympathetic dystrophy or complex regional pain syndrome.
Suspect a psychogenic etiology
4. Fixed painful postural torticollis following trauma is not
uncommon and many of these case appears to be psychogenic
in etiology
PREDOMINANT MOVEMENT FEATURE IN
PSYCHOGENIC MOVEMENT DISORDERS
Predominant feature N Percent

Tremor 467 37.5

Dystonia 365 29.3

Myoclonus 146 11.7

Gait disorder 114 9.2

Parkinsonism 60 4.8

Tics 29 2.3

Other 64 5.1

Total 1,245 100

Deuschi, Koster, Lucking, Scheidt: Diagnostic and
pathophysiological aspects of psychogenic tremor

1. Less than 2% of patients presenting with tremor

2. Generalised body shaking:
a. Usually cease during the examinations because they are
exhausting for the patient
b. Bizzare presentation
c. Variable tremor frequencies
d. Major differential diagnosis is orthostatic tremor
3. Limb tremor:

a. Coactivation sign – If rigidity decreases during testing ,

tremor lessens as well

b. Absence of finger tremor – finger tremor is uncommon

in psychogenic tremor

c. Tremor increases with increase of load

d. Sudden onset – resting tremor is present

OTHER HELPFUL FEATURES TO DIAGNOSE
PSYCHOGENIC TREMOR

A. About half of psychogenic tremors are coherent between

the two arms, while most involuntary tremors are
incoherent.

B. Psychogenic tremors show larger tremor frequency and

higher intraindividual variability while tapping to the sound
of an auditory stimulus.
 PSYCHOGENIC DYSTONIA :

1. Sudden onset, tonic postures(not action dystonia),fixed

dystonia,pain,contractures- are common features.

2. The presence of other types of abnormal(incongruous) movements

help make the diagnosis of psychogenic etiology.

3. Painful dystonia (causalgia-dystonia; reflux sympathetic dystrophy) is

a controversial disorder.
ABNORMAL PHYSIOLOGY IN PSYCHOGENIC DYSTONIA :

• An interruption of the study by Espay and colleagues and imaging studies

showing changes in brain physiology in psychogenic neurologic disorders
is that the CNS adapts its physiology to fit the motor or sensory behavior.

• Or does brain physiology occur first, and the motor manifestations

follow?
 SOME PSYCHOGENIC GAIT PATTERNS
• Keane(1989): ataxia,trembling,dystonia,truncal
myoclonus,camptocormia,buckling knee

• Hayes et al(1999): exaggerated effort, extreme slowness,variability

during the day, unusual or uneconomic postures, collapse, convulsive
tremor, distractability

• Morris et al(2006): exaggerated effort, fatigue with groans and sighs,

extreme slowness, appearance of pain with grimace, knee-buckling,
unusual postures, astasia-abasia.
 TOTAL MIXED TYPE PURE TYPE
Features of gait in psychogenic gait disorder
Patient number 118 102 16

Slowing 22 21 1

Dystonia 21 20 1

Bizarre 14 12 2

Astasia-abasia 14 11 3

Buckling of the knee 9 4 5

Tightrope walking 8 7 1

Trembling 5 4 1

Stiff-legged 5 5 0

Dragging 4 4 0

Scissoring 5 4 1

Truncal myoclonic 4 4 0

Fatigue 3 3 0

Waddling 3 2 1

Ataxia 1 1 0
Lang AE, Koller, Fahn S.
PSYCHOGENIC PARKINSONISM :
• Rigidity (six patients): had features of voluntary resistance, often
decreasing with distraction and/or activating synkinetic movements
in opposite limbs.

• Arm swing was usually diminished or absent on the affected side;

however, the arm could be held tightly to the side or cradled in front
of the patient.

• Slowness of movement usually lacked the typical decrementing

amplitude feature of bradykinesia-i.e., delibeate siowness instead
 Features in common with psychogenic
movement disorders

1. The slowness, gait abnormalities and postural instability(12

patients) often had bizarre , inconsistent or incongruous
features.

2. ‘Give – way’ weakness and non- organic sensory

disturbances were common ( 10 patients)

3. Remissions, sometimes with placebo treatment or

psychotherapy were occasionally seen(5pts)
ORGANIC TICS VS. PSYCHOGENIC MOVEMENT DISORDERS :

• Waxing & waning

• Moving from one body part to another

• Suggestibility

• Paroxysmal nature of tics

• The above features are congruent & consistent with organic

tics, but they are not features of almost other types of organic
movement phenomenology i.e., would be incongruent
• IT IS ESSENTIAL TO BE KNOWLEDGEABLE ABOUT THE NATURAL
FEATURES OF A DISORDER

• To help establish a diagnosis of psychogenic tics, one depends on

the presence of

1) incongruous other types of movements

2) sudden onset

3)clues from neurological examination

4) how the tics developed e.g., mass hysteria

REMARKABLE IMAGING FINDINGS IN
PSYCHOGENIC DISORDERS
• Rather than being normal , these studies have revealed examples of
abnormal brain function
ABNORMAL BRAIN PHYSIOLOGY IN
PSYCHOGENIC DYSTONIA

• Patients with psychogenic dystonia have the same abnormalities of

intracortical inhibition, cortical silent period and spinal reciprocal inhibition

as patients with primary dystonia.

APPROACHES TO THE PATIENT SUSPECTED OF HAVING A
PSYCHOGENIC MOVEMENT DISORDER :

1. Diagnosis before disclosure to patient

Before disclosing the diagnosis , do all the necessary & reasonable tests
to feel comfortable & secure that an organic basis for the symptoms
has not been overlooked

* Sleep study with video recording to observe the movements & EEG
monitoring to determine if patient is asleep

* Conversion of symptoms can occur in sleep

* Motor physiology for myoclonus, tremor & startle

2. How to inform the patient & family of the diagnosis in an
outpatient setting:

a. After the necessary diagnostic studiesare complete, be

reasonably confident in the diagnosis.

b. Then use tact, more tact and a lot more tact.

c. Explain the findings/phenomenology, e.g., tremor , dystonia,

myoclonus, etc..

d. mention that there are many causes for this problem and name
some e.g., brain tumour , degenerative disease, vascular,… and
stress so that the brain’s physiology produces these movements.
3. Work with a psychiatrist:
a. Someone with an interest in treating conversion disorders, i.e.
specializing in neuropsychiatry.
4. Explain the treatment approach to the patient and the family:

Proper treatment requires:

a) Finding out the source of stress & eliminating it with the help of
a psychiatrist.

b) Retraining the muscles with a physiotherapist

c) Desensitizing sensory stimuli to eliminate excessive reactions to

them ( occupational therapist)

d) normalising neurotransmitters ( treating depression) by

psychiatrist
5. Try to admit the patient to hospital . Justify the need for intensive PT.

a) To carry out treatment strategy of 3-pronged approach –

psychotherapy, PT/OT , medication

b) Convince the insurance company that getting the patient better after
a short stay in the hospital will save them tons of money in the long run
than if the patient is not treated & remains with his/her disabilities.

c) Prior to admission, walk over to in- patient PT and OT and explain the
situation that they play a key role in helping the patient get better
6. Working with the patient (and family) in the
hospital:
a. See the patient daily. Constantly give
encouragement and emphasize positive
developments.
b. This is a team approach (Nx, ψ, PT, OT)
c. The Nx provides the neurological information (as
mentioned earlier ) and the diagnosis .
d. The ψ then describes what he/she has
uncovered so far and what the course of
treatment will be.
e. “ Good cop – bad cop”.
7. Always be positive and absolute with the patient as if you are
secure with the diagnosis.

a) Do not convey uncertainity, else the patient will continue to

doubt the diagnosis and fail to respond to therapy

b) Always give positive reinforcement that the symptoms will

progressively improve with time, as the muscles “ are being
retrained to move more appropriately”.

c) Praise the patient daily for every improvement seen.

8. The use of placebo is debatable.

a) It is a quick and easy way to see if the symptoms go away ,

thus establishing the diagnosis.

b) Placebo therapy often backfires. When the patient finds out

, he/she will stop trusting you.

c) Its use without informing patients has been considered

unethical by some and could lead to legal challenge by the
upset patient who placed his/her trust in you.
9. Do not underestimate the severity of the underlying psychiatric

illness. Some of these patients are prone to commiting suicide.

10. Factitious disorders and malingering are usually not benefited.

Symptoms will disappear only when the patient is ready to give

them up.

11. Somatoform disorders can usually be treated. In some patients,

the symptoms may return when they go back home, despite the

patient being aware that it is due to an emtional problem.

PSYCHOGENIC MOVEMENT DISORDERS :

TYPES OF MOVEMENTS
Single type 21%
Multiple types 79%
Continuous movements 45%
Intermittent/ paroxysmal 55%
15 patients with hand tremor 93%
dominant hand
Abrupt onset (usually inciting event) 60%
Spread from initial site 43%
 Clinical features
Previously erroneously diagnosed as organic 75%
3 with a diagnosis of MS despite negative lab tests
False weakness 37%
False sensory exam 8.7%
Pain & tenderness 17.4%
Startle 29%
Psychogenic seizures 11.6%
Disabled 65%
Head trauma 25%
Peripheral trauma 12.5%
 Psychiatric aspects
Conversion disorder 75%
Somatization disorder 12.5%
Factitious 8.3%
Malingering 4.2%
Accompanying
depression 71%
anxiety 17%
Hypnotizable
highly 36%
mild – moderate 41%
 Treatment

Accepted diagnosis & was treated 70%

Refused diagnosis & treatment 30%
Psychiatrically treated patients
Family sessions 58%
Hypnosis 88%
Physiotherapy 42%
Placebo 13%
Antidepressants 71%
ECT 8%
 Results of treatment

Complete relief 25%

Considerable relief 21%
Moderate relief 8%
Relapse 4%
Partial relapse 17%
No improvement 12%
 Results of treatment in adults

Working full time 25%

Working part time 10%
Functioning at home 15%
Disabled 30%
PALLIATIVE CARE & MOVEMENT DISORDERS :-
• Palliative care is a medical speciality focused on caring on patients
and caregivers affected by serious and life limiting illness.
• It offers a comprehensive approach to health and wellbeing by
focusing on aggressive treatment on total pain caused by serious
illness.
• Total pain is key concept in palliative care
• It includes physical,social,emotional,spiritual distress caused by
serious illness.
• Role of palliative care in improving quality of life in
neurodegenerative disorders.
Conclusion :
• Acute onset
• Static course
• Spontaneous remission
• Consistently inconsistent character of movements in
• Amplitude
• Frequency
• Distribution
• Selective disability
• Lessening with distraction
• Bizarre
• Deliberate slowness
• More at rest
• Response to placebo/ suggestion
• Uneconomic postures