In 1922, Sir Henry Head wrote: “…Hysteria is sometimes said to imitate organic affections; but this is a highly misleading statement. The mimicry can only deceive an observer ignorant of the signs of hysteria or content with perfunctory examination.”1 Although in many cases of psychogenic movement disorders (PMDs) the nature of the problem is quite obvious from the first patient encounter, in the majority the diagnosis requires careful analysis of the history and the phenomenology of the abnormal movements and occasionally prolonged periods of observation and assessment. In general, abnormal movements and postures due to primary psychiatric disease are among the most difficult diagnostic problems in neurology even for the most experienced neurologist.
More recently, legal problems have increased the burden on such diagnoses. With the increasing risk of being sued by a mistake either way, either subjecting a patient to potentially dangerous diagnostic procedures and treatment options or denying potentially effective treatment options, the responsibility for accurate diagnosis has increased tremendously. Disputes involving work-related injuries and resulting compensation have become a major legal issue in most countries, and the increasing frequency of psychogenic or factitious disorders in these circumstances have taken the diagnosis of a PMD to a greater dimension while we are still looking for good biological markers to aid us in the diagnosis of organic forms of movement disorders. A recent survey of Movement Disorder Society members has shown that the majority (51%) of treating physicians still go through extensive, and expensive testing even when patients present with definitive evidence of a PMD (A. Espay, personal communication).
In this chapter, we will review the varied manifestations of PMDs and provide guidelines for the diagnosis and approach to therapy of these patients.
In the 1880s, Charcot was fascinated by “hysteria” directing much attention to its definition, analysis, treatment, and research.2 In one of his Tuesday lessons at the Salpêtrière, he presented a young woman who developed a contracture and deformity of her right foot 5 days following a fall. In his teachings, such a contracture should have been corrected as soon as it appeared. In this particular case, he decided to watch the progression of the disorder over 4 days without interfering. He taughtthat in such cases the treatment involved inducing a second attack to make the “fixed” contracture completely disappear. He used “hysterogenic points” to provoke such a transient attack as a form of therapy in the treatment of static hysteric signs. From the patient description, it appears that Charcot was dealing with a case of what we would now term “psychogenic dystonia.”
According to Charcot, posttraumatic contractures were more frequently seen in hysterics. Charcot proposed that hysteria was not restricted to women but was also common in males, especially working-men,3 children,4 and effeminate men.5 Freud3 also reported Charcot's observations that many conditions previously ascribed to alcoholic or lead poisonings were, in fact, hysterical.