Psychogenic nonepileptic seizures and psychogenic movement disorders: two sides of the same coin?

Abstract

Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are commonly seen in Neurology practice and are categorized in the DSM-5 as functional neurological disorders/conversion disorders. This review encompasses historical and epidemiological data, clinical aspects, diagnostic criteria, treatment and prognosis of these rather challenging and often neglected patients. As a group they have puzzled generations of neurologists and psychiatrists and in some ways continue to do so, perhaps embodying and justifying the ultimate and necessary link between these specialties.Keywords: psychogenic nonepileptic seizures, psychogenic movement disorders, conversion disorder, hysteria. RESUMOCrises não-epilépticas psicogênicas (CNEP) e distúrbios do movimento psicogênicos (DMP) são comuns na prática e na atualidade são melhor categorizados no DSM-V como distúrbios neurológicos funcionais/desordens de conversão. Esta revisão enfatiza os principais dados históricos, epidemiológicos, clínicos, critérios diagnósticos, tratamento e o prognóstico destes pacientes, frequentemente negligenciados e desafiadores, os quais, como um grupo, tem intrigado gerações de neurologistas e psiquiatras, caracterizando, de forma justificada o elo definitivo entre estas especialidades.Palavras-chave: crises não-epilépticas psicogênicas, distúrbios do movimento psicogênicos, distúrbio conversivo, histeria.In the medical sciences, a diagnosis is established when a level of certainty regarding the nature of a condition is achieved. Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) share a slightly less linear diagnostic route. Historically, making a conversion diagnosis required ruling out the originally considered medical diagnosis, i.e., it is neither epilepsy, nor a neurogenic movement disorder. Only then a non-neurologic (in the sense of not resulting from epileptogenic or known motor circuitry imbalance) condition is suspected and raised to the level of diagnosis 1 . This kind of diagnosis has intrigued generations of physicians and spared no culture, gender or age. A diversity of symptoms, including motor, sensory, cognitive, and/or behavior symptoms are present in these presentations. Patients with PNES or PMD frequently are misdiagnosed as having their initial suspected neurological diseases, and ultimately pose a diagnostic and treatment challenge to many clinicians. Interestingly, it was perhaps this varied presentation that has captured the attention of many professionals through the centuries and lead to the construction and recognition of a very particular diagnosis. Two rather advanced historic civilizations, Egyptians first, and then the Greeks, posited that a displaced hystera (womb), and the consequent suffocation that it produced, was the source of choking, mutism, paralysis and fainting 1 . Hysteria, a natural development on this concept, was claimed as an explanation for similar phenomena in women and reached almost epidemic proportions in the late 19 th century. By th...

Psychogenic facial movement disorder: a case report

“…A strong association between functional movement disorders and exposure to phenotypically similar movement disorder models was shown [10]. Response to placebo, suggestion or psychotherapy rather than improvement with drug treatments is another finding in these patients [1,3].…”

“…Features that are regarded as characteristic of PMD include abrupt onset, fluctuations in symptom severity, spontaneous remissions, inconsistency, incongruency, distractibility, suggestibility, bizarre movements, deliberate slowness of movements and disproportional functional disability. Other clues are a dramatic increase of PMD by direct observation, physical or psychosocial triggers, secondary gain and normal diagnostic studies [3,6,9,12]. Somatoform disorders are also very common [3].…”

“…Other clues are a dramatic increase of PMD by direct observation, physical or psychosocial triggers, secondary gain and normal diagnostic studies [3,6,9,12]. Somatoform disorders are also very common [3]. A strong association between functional movement disorders and exposure to phenotypically similar movement disorder models was shown [10].…”

“…Presentation with the form of any known organic movement disorder can be seen [1]. The frequency of PMD in movement disorders ranges between 2-4% and nearly 30% of patients admitting to outpatient neurology clinics are psychogenic in nature [2][3][4]. It may cause significant distress or impairment in social, occupational ,or other important areas of functioning [5].…”

Functional disorders continue to pose diagnostic and therapeutic challenges to neurologists

“…A recent pilot randomized controlled trial showed significant seizure reduction and improved comorbid symptoms and global functioning for psychogenic nonepileptic seizure patients that underwent cognitive behavioral treatment with or without sertraline, while treatment-as-usual or sertralineonly showed no benefit 8 . In this issue of Arquivos de Neuropsiquiatria, DePaola et al provide an extensive review of historical aspects, epidemiology, clinical features, diagnosis, and prognosis of psychogenic nonepileptic seizures and psychogenic movement disorders 9 . The authors also review the limited published data that analyzed possible common features of both disorders.…”