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Functional Or Psychogenic Movement Disorders: an Endless Enigmatic Tale OPINION ARTICLE published: 27 February 2015 doi: 10.3389/fneur.2015.00037 Functional or psychogenic movement disorders: an endless enigmatic tale Carlo Dallocchio1*, Antonio Marangi 2 and MicheleTinazzi 2 1 Division of Neurology, Ospedale Civile, Azienda Ospedaliera Della Provincia Di Pavia, Voghera, Italy 2 Section of Neurology, Department of Neurological and Movement Sciences, University Hospital of Verona, Verona, Italy *Correspondence: [email protected] Edited by: Antonio Pisani, Università degli Studi di Roma Tor Vergata, Italy Reviewed by: Maria Stamelou, University of Athens, Greece Tommaso Schirinzi, Università degli Studi di Roma Tor Vergata, Italy Keywords: functional neurological symptom disorder, psychogenic movement disorders, conversion disorder, somatoform disorder, psychosomatic symptoms, psychological therapy, physical activity Functional/psychogenic movement disor- of a conversion disorder (or “functional are not yet fully demonstrated, making the ders (F/PMDs) are a valuable model for neurological symptom disorder”) is not diagnosis more acceptable to patients. all medically unexplained symptoms and necessary, while it has been highlighted By the late nineteenth century, psycho- raise arduous challenges for diagnosis and the importance of an accurate neurologi- analytic theory ruled medical reasoning treatment indicating our restricted under- cal examination, in order to demonstrate about these symptoms. Originally referring standing of the true pathogenesis that the presence of positive diagnostic physi- to these disorders as hysteria, neuropsy- causes them. cal symptoms and signs typical of PMDs, chiatrists began illustrating the various A multiplicity of terms, such as “con- which are not typically seen in other move- clinical phenomenological aspects of such version,”“somatization disorder,”“psycho- ment disorders (4). Moreover, it should be disorders. Charcot proposed that hysteria somatic,” “neuropsychiatric,” “dissociative emphasized that the term “psychogenic” was congenitally derived, and that lesions motor disorders,” and so on, have been turns out to be linguistically faulty, imply- responsible for this condition might ulti- applied to describe neurological symptoms ing that the movement disorder has “given mately be found somewhere in the brain. that cannot be attributed to any known birth” to the psychiatric problem. Thus, in Today, we know that neuroimaging stud- organic disease (1). the DSM-5, F/PMDs are included under ies have shown an abnormal network of In recent years, there has been a great the broader category of “functional neuro- neuronal activation in brain function in debate about the use of the terms “psy- logical symptom disorder”; moreover, the patients with PMDs (10). Regarding ther- chogenic” and “functional,” which is far umbrella category of “somatoform disor- apy, in that era hypnosis was used as a from being solved. ders”disappeared to emphasize more desir- powerful tool for demonstrating how, on The term “psychogenic” is common able clarity and to point up the prominence occasion, subconscious motivations could and classically used in the movement dis- of somatic symptoms that cause distress in generate a variety of disabilities resembling order literature (2), and it refers to a these disorders (4). those seen in the context of bona fide neu- presumed causal relation between psy- Hence, some authors argue that the rologic disease; hence, paralysis, tremors, cho(patho)logical factors and the gener- term “functional” better reflects the state convulsions, and sensory alterations were ation of abnormal movements. The role of the evidence regarding the pathophysiol- identified as sometimes being due to hys- of psychopathological triggers still remains ogy of psychogenic disorders, and its use is teria. Subsequently, different etiologies of poorly understood; however, it has been encouraged (1,5–8),as it could favor accep- dystonia, tremor, myoclonus, and other shown that patients with PMDs frequently tance at the time of diagnostic debriefing. movement disorders were recognized. present a higher rate of major emotionally Moreover, this term is freer from etiologi- Emerging neurobiological evidence, stressful or traumatic life events when com- cal assumptions, which are poorly under- neurophysiological findings, and improved pared to healthy volunteers; at the same stood, and does not reinforce the dualis- neuroimaging have provided significant time, the evaluation of similar parameters tic thinking regarding the relation between insights about the psychogenicity of in patients with hand dystonia reveals very mind and brain (1). While some authors the diagnosis; nevertheless, it remains few differences from patients with FMDs assert that subjects who present with these unknown whether the alterations reflect (3). Hence, given that relevant psychologi- disorders commonly perceive themselves etiological mechanisms (10). F/PMDs are cal factors may not be demonstrable at the as “dysfunctional” rather than “functional” generally also associated with emotional time of diagnosis, in the recently published (9), it seems reasonable to prefer the use of and functional disturbances (11), but func- Diagnostic and Statistical Manual of Men- this term in clinical practice,because it pro- tional imaging data show that subjects tal Disorders (DSM-5),the requirement for vides the undeniable advantage of avoiding with F/PMDs have sensory deficits and the demonstration of the “psychogenicity” the reference to etiological theories, which impairment of perceived voluntariness and www.frontiersin.org February 2015 | Volume 6 | Article 37 | 1 Dallocchio et al. Functional or psychogenic movement disorders volition, indicating that F/PMDs are not and psychologists as well (17). This atti- patient and no psychosomatic factor in a manifestations of intention (12). More- tude runs the risk of creating a type of patient with an evident functional tremor. over, how emotional stressors originate doctor shopping behavior in patients who Faced with the heterogeneous clinical an alteration in the dynamic integration feel rejected by medicine and not accepted presentation of all functional neurologi- between awareness of agency and instant in relationships with physicians, leading to cal disorders, it is clearly useless from an sensation, and the control of bodily func- an abnormal behavior constantly search- operating standpoint to have a single diag- tion still remain to be clarified (13). ing for check-ups, exams, medicines, etc. nostic category, which many patients and More in-depth interaction of interests Another possible consequence is defensive therapists are looking for. On the other between neurosciences and cognitive psy- medicine by physicians due to a fear of hand, it is also clear that technical instru- chology seems to demonstrate a very close being accused of malpractice and which ments such as scales, questionnaires, neu- connection between cerebral events and leads to abnormal prescribing conduct. roimaging, and laboratory investigations mental experiences. These results indicate On the other hand, even managing to are needed to reach a diagnosis. The essen- more than just a limitation to the con- explain to patients that they have a “func- tial point for those who have to deal with cept of the mind as a separate metaphysical tional” or “non-organic” disorder is not these pathologies is to think and work with entity that operates independently from the always easy. We could minutely argue in different procedures, attempting to care- brain, and seem to recognize the uncon- favor of the use of others terms as “pri- fully consider and differentiate the type scious mind as the center of brain activity mary,” “distinctive,” “interactional,” etc., and level of association between psycho- that controls our behavior and determines therefore trying to avoid the psyche/body logical elements and physical conditions our emotional desires and other mental dualism, but the main objective is not cre- as much as possible (20, 21). Unlike what inclinations (14). As such, the mind does ating an ambiguous relationship between is commonly believed, patients with func- not intervene by changing the universal patients who live inside the complexity of tional neurological symptoms want to be rules that neural pathway functioning is their bodies and physicians who observe heard and receive emotional support, even based on, but exercises a control of these the unhealthy body as a three-dimensional before receiving diagnostic findings, which pathways (15). There may be a pathologic object, which can be measured with analy- explain their symptoms. unconscious influence on movement pro- ses and examinations (18). From a clinical There is no consensus even among the duction associated with a disconnection viewpoint, the divergence in the physician– experts about the best treatment approach between movement production and sense patient relationship is clear when listening to patients with F/PMDs. Actually, psy- of volition (16). Besides, earliest affective to the terms used by patients and those chological therapy (22) as well as dif- or stress-related factors, neuropsycholog- used by physicians to describe the same ferent physical approaches (23, 24) seem ical and psychosocial processes, perhaps symptoms (19). Speaking about two differ- to improve symptoms, but well designed involved primitive reflexive mechanisms of ent aspects of the body should be avoided, prospective studies are needed. Therefore, protection and alertness
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