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PSYCHOTHERAPY EFFECTIVE IN TREATING PSYCHOGENIC MOVEMENT DISORDERS
SAN FRANCISCO—Outpatient psychotherapy and appropriate use of psychiatric medication can be a successful intervention for patients with psychogenic movement disorders, according to Vanessa K. Hinson, MD, PhD. “The symptoms [of psychogenic movement disorders] are either the manifestation of underlying psychiatric disease or malingering. In terms of the underlying psychiatric diagnosis, currently—by DSM-IV criteria—we’re dealing with either somatoform disorder or factitious disorder,” she remarked in her address to the 56th Annual Meeting of the American Academy of Neurology. Dr. Hinson is Director of the Medical University of South Carolina’s Movement Disorders Program in Charleston.
A FREQUENT PHENOMENON
“Abnormal movements are really among the most frequent symptoms of all psychogenic neurologic disorders,” Dr. Hinson said. It is estimated that about 2% to 3% of the patients in movement disorder clinics suffer from psychogenic movement disorders, she noted. “Their symptoms can mimic the full spectrum of organic involuntary movements. They can affect gait and speech or present as bizarre and quite undifferentiated movements. They’re often disabling, but they lack any generally accepted treatment strategies.”
The objective of Dr. Hinson’s study was to evaluate the efficacy of outpatient psychotherapy and psychiatric medication adjustment as a treatment for psychogenic movement disorders. She and her colleagues recruited 10 subjects. The diagnosis of psychogenic movement disorder was made by a movement disorders specialist and confirmed by a panel of seven physicians upon a video review. Treatment consisted of weekly individual outpatient psychotherapy sessions for 12 weeks; antidepressant or anxiolytic medications could be started as deemed necessary by the psychiatrist.
SCALING THE DISORDER
Dr. Hinson and colleagues videotaped the patients before and after treatment. The tapes were then rated in a randomized order by a blinded rater using the Psychogenic Movement Disorder Rating Scale (PDMRS). “The PDMRS takes account of movement phenomenology and movement distribution, as well as the duration, severity, and global incapacitation of the abnormal movement,” Dr. Hinson explained. “The scale has a second part that rates gait and speech disorders, and we come up with a summary score based on the phenomena, the functions, and the total score.”
The primary outcome for the study was the change in the total PDMRS score, Dr. Hinson said. Patients were also diagnosed according to DSM-IV criteria by a psychiatrist before and after treatment. They were administered the Hamilton Depression Scale, the Beck Anxiety Scale, the MMPI-2, and the Global Assessment of Function Scale.
SIGNIFICANT THERAPEUTIC BENEFITS
Dr. Hinson reported that nine of the 10 subjects (six Caucasian, three African-American; seven women; mean age, 31.3) completed the study. The duration of symptoms varied between less than eight months in eight subjects and 78 months in one subject, she noted. “Most commonly we found action tremor in eight patients, followed by myoclonus, dystonia, resting tremor, bradykinesia, speech and gait disorders; most patients actually suffered from a variety of symptoms.”
All subjects were diagnosed with a conversion disorder, and seven had psychiatric comorbidities. Five suffered from major depressive disorder, others from posttraumatic stress disorder, personality disorder, anxiety disorder, or bipolar disorder, Dr. Hinson said.
“Patients received once-weekly psychotherapy for 12 weeks, and the psychiatrist altered medication in a few cases,” she said. “When we looked at the total psychogenic movement disorder rating scale score, the mean total score for all patients decreased from 71.2 to 29 after treatment. This was statistically significant. When you look at the function subscore, that decreased from 7.4 to 2.1, and that was also statistically significant,” she added.
In terms of global incapacitation, “all patients improved quite drastically except for one who remained stable and one who showed an increase of abnormal movement as judged by the blinded rater. However, in terms of the global assessment of function, we can see that the patient who got worse in terms of movement actually improved in this score,” she remarked.
In terms of psychiatric assessment, “what we found was a dramatic improvement in Hamilton Depression scores from a mean of 14.8 before treatment to a mean 3.9. Beck anxiety scores improved from 19.7 before to 4.9 after treatment, and Global Assessment of Function score improved from a mean 62 to a mean 69.”
Dr. Hinson concluded, “outpatient psychotherapy and appropriate use of psychiatric medication can be a successful intervention for patients with a psychogenic movement disorder. Further studies now will focus on stability of improvement and also include a randomized study design,” she said.
—C. Justin Romano
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