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Clinical Pearls on Best Approaches to Psychogenic Movement Disorders: Page 3 of 4

Clinical Pearls on Best Approaches to Psychogenic Movement Disorders: Page 3 of 4

It is difficult for a neurologist who doesn't see a lot of patients with PMD to make a diagnosis, conceded Jankovic. "I would say that the vast majority of these patients—80% or 90%—had another diagnosis before they saw us," he said.

There is also a risk that someone with an organic movement disorder will be misdiagnosed with a PMD. "Before we disclose the diagnosis to the patient, we want to be 100% sure that this is a correct diagnosis and that we have excluded all organic causes," said Jankovic. This is why it is a good idea to refer patients with a suspected PMD to a movement disorder center.

The diagnosis should be made by a neurologist who specializes in movement disorders rather than by a psychiatrist or psychologist, emphasized Jankovic. He said that it is extremely frustrating to diagnose a PMD, send the patient to a psychologist or a psychiatrist for treatment, and have that specialist tell them they are psychologically "fine" and that their disease is organic—a surprisingly common occurrence.

Hinson agreed that a neurologist who specializes in movement disorders should be tasked with making the diagnosis of a PMD, but she pointed out that psychiatrists can help refine the diagnosis and identify whether the PMD is related to a conversion disorder, somatoform disorder, factitious disorder, or to malingering.

Hinson reported that neurologists often refer cases to her when they are uncertain about the diagnosis. Other times, the referring neurologist has made the diagnosis but the patient has refused to accept it. Finally, some neurologists shy away from making the diagnosis themselves because they fear that the patient will not be receptive to it.

How can neurologists get patients to accept a diagnosis of PMD?

"You need to deliver the diagnosis with a lot of sensitivity so that the patient trusts the doctor, does not feel rejected, and buys into the treatment process," said Hinson. The first step is to acknowledge that the patient has a movement disorder. "I say, for example, 'You have a tremor disorder. There's no doubt about that.'" Hinson then goes on to explain that there are different causes of tremor. "I say that there's parkinsonian tremor, there's essential tremor, there's drug-induced tremor, and there's psychogenic tremor."

She then goes through each of these causes and explains why the patient's disease either does or does not fit the criteria. "I say, your tremor does not fit into Parkinson's type tremor because of this and that, and patients can understand this . . . They think, 'my tremor is different.'"

Finally, she delivers her conclusion: "It's not Parkinson's, it's not essential tremor, it's not drug- induced; your tremor falls in the category of psychogenic tremor. So what does that mean?" She then explains to the patient that the emotion center in the brain is tightly linked with the motion center in the brain, and if there's an emotional disturbance, the body can react with motor symptoms.

"I often make the analogy that on a small scale, if someone who is supposed to speak in public is nervous, their hands might start shaking, or if they're embarrassed, their face might get red, so emotional feelings can translate into physical symptoms." She said that most patients are receptive to the analogy and understand what she is saying.

"Then I underline that the patient has a movement disorder but that the origin of the movement disorder is not cell death or neurodegenerative disease like in Parkinson's. I stress that the disorder is an abnormal function of the brain that is triggered by emotions."

Hinson also emphasizes that the disease is curable and that the movements can go away because brain damage is not involved. She said that patients like hearing that brain damage is not an issue and that they can "get better."

Finally, Hinson tells them that the only way for them to improve is to follow through with treatment from a psychiatrist. "Because I tell them where I'm coming from and how I make the diagnosis, they're usually 'with' me [about the diagnosis and treatment recommendation] and will follow up with my psychiatric colleague."

Jankovic said that about 99% of his patients accept the diagnosis, but admitted that this wasn't always the case. "I'll be honest with you, when I first started seeing these patients, my success rate was much lower than that. I didn't know exactly how to approach them."

He agreed with Hinson that a sensitive delivery is essential. Too often, patients have the impression that the physician does not believe them and thinks the problem is "all in their head." "My feeling is that I have to convey to them that I do believe them, I do believe that what they're telling me bothers them, and that these symptoms are not entirely under their control."

Jankovic said that he emphasizes stress as the cause of the disorder and attempts to identify what type of stress might be at play. "I would say that in 80% or 90% of cases we can clearly identify what the stress factor might be at the time of the initial visit." He added that some patients will initially deny having stress as a precipitating factor but that further interviews with the patient, family members, and friends will generally reveal a specific stress trigger.

Kompoliti agreed that the diagnosis is difficult for patients to accept. She likes to emphasize the positive. "I tell them, 'this is the best news I could have given you today. If you had Parkinson disease, it would have been bad news: it's progressive, you have it for the rest of your life, and it could put you in a wheelchair, but you don't have that.'"

Her next step is to explain how important it is to act quickly to begin treatment because patients with recent-onset PMD have the best chance of getting better.


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