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Psychogenic Movement Disorders and Other Conversion Disorders

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Mark Hallett, Anthony E. Lang, Joseph Jankovic, Stanley Fahn, Peter W. Halligan, Valerie Voon, and C. Robert Cloninger. New York, NY: Cambridge University Press; 2012; ISBN: 978-1-107-007345, pp 336; $120 (hardcover).

Psychogenic movement disorders, as the editors of this volume write, are “essentially defined as involuntary movement disorders presumed to be of psychological/psychiatric origin” (p xi). These disorders attract a lot of attention from the lay public and physicians alike because of the variety of difficult to categorize “visible” phenomenology. Psychiatrists and neurologists have been trying to understand and interpret them since the time of Jean-Martin Charcot and Sigmund Freud. The explanatory frame of conversion “advocated by Freud, is that a psychological symptom is converted to a somatic symptom as a means of dealing with the psychological symptoms” (p xi).

Conversion disorders, especially those with a pronounced movement symptomatology, have straddled the area between psychiatry and neurology and have been of keen, yet separate, interest in both fields. Actually, as pointed out in this book, we still have a fundamental problem with classification of these disorders because we have separate neurologic and psychiatric classifications (p 69). However, as the editors point out, neurologists and psychiatrists clearly need to work together in managing these disorders. “Neurologists and not psychiatrists must make the diagnosis of a psychogenic movement disorder. Neurologists are trained in movement disorders and their differential diagnosis. However, psychiatrists have an important role in further exploring the possible psychodynamic and stress-related factors, and in collaboration with a neurologist, planning a therapeutic strategy” (p xii). Interestingly, despite the amount of attention these disorders attract, there has not been much research, especially interdisciplinary, in this area. The Movement Disorder Society, the National Institute of Neurological Disorders and Stroke, and the National Institute of Mental Health have jointly sponsored conferences on these disorders to increase the interdisciplinary dialogue focused on them. This volume is the outcome of the Second International Conference on Psychogenic Movement Disorders and Other Conversion Disorders, which was held in Washington, DC, in April 2009.

The editors gathered an international team of 78 psychiatrists, neurologists, psychologists, and students who authored 43 chapters. The book is divided into 4 sections: Clinical issues (18 chapters); Physiology (13 chapters); Assessment (4 chapters); and Treatment (8 chapters). The book also includes an Appendix with legends to a unique part of this volume: a DVD with video examples of movement disorders. As it frequently happens in volumes based on conferences and symposia (where everybody is invited to contribute), chapters are of uneven quality, some being well-written and comprehensive and others being short and not contributing much, if at all.

Some chapters in the first section on clinical issues are good and useful. An example is the chapter devoted to the phenomenology of psychogenic movement disorders, which is filled with well organized tables on the differences among various clinical and phenomenological syndromes, such as the differences between psychogenic vs organic tremor; psychogenic vs organic dystonia; psychogenic vs organic myoclonus; and psychogenic vs organic parkinsonism—all of which are included in the book’s supplemental DVD.

There are 3 brief chapters devoted to clinical issues of psychogenic disorders in children, which in a way demonstrate the problem of books originating at a conference—these chapters could have been combined into 1. I always have been puzzled by psychogenic nonepileptic seizures (PNES) and I appreciated the chapter devoted to this topic. PNES are time-limited, paroxysmal changes in movements, sensations, behaviors, and/or consciousness, presenting like epileptic seizures but not associated with epileptiform activity (p 71). I also learned that, “nonepileptic seizures can be physiological or psychogenic in origin and can be difficult to distinguish from epileptic seizures, with both seizure types showing alterations in behavior, consciousness, sensation and perception” (p 71) and that video electroencephalography remains the gold standard for PNES diagnosis (p 71). This chapter also contains a good table of behaviors that distinguish PNES from epileptic seizures.

The section devoted to physiology, in its entirety, demonstrates the perils of books based on conferences. It includes several imaging chapters, a section on evoked potentials in the assessment of patients with suspected psychogenic sensory symptoms, and further chapters of interest perhaps for a few, but not the general readership or busy clinicians.

The section on assessment contains 4 slightly more useful chapters on rating scales for psychogenic movement disorders, quality of life in psychogenic disorders, psychiatric testing, and finally on diagnostic considerations for the assessment of malingering within the context of psychogenic movement disorders. The most useful was the last chapter. Here I appreciated the statement that “Practitioners must view with frank skepticism any claims by psychologists or other clinicians that their testing confirms, or even supports, feigned or malingered PMD [psychogenic movement disorder]” (p 245).

The last section addresses treatment issues from prognosis, explaining the diagnosis, psychotherapy, and pharmacotherapy to inpatient treatment. The chapter on explaining the diagnosis includes a listing of core components of explanation, potential advantages and disadvantages of both psychological and functional explanations, and other issues useful in discussing a PMD diagnosis. The chapter on psychotherapy briefly addressed a host of modalities that may be useful in these disorders and other therapeutic issues.

The most valuable part of the book, in my opinion, is the video collection on the supplemental DVD and the Appendix with video legends. The collection includes 16 cases of psychogenic tremor; 18 cases of psychogenic dystonia; 13 cases of psychogenic myoclonus; 20 cases of psychogenic parkinsonism; 27 cases of psychogenic gaits; and 12 cases of miscellaneous psychogenic movement disorders. These video vignettes were collected by several authors, and the Appendix states that all patients in these clips had clinically definite psychogenic movement disorders, often with additional confirmatory historical or clinical features not included in the clips. I doubt that such a collection is available anywhere else.

The book has many weaknesses and certainly could be pruned to about half of the text, unless one is interested in real minutiae of the latest in physiology of psychogenic movement disorders. Also, it is not an inexpensive text. However, I feel that the video collection is invaluable. Clinicians interested in these disorders can learn a lot from this collection. Those teaching about movement disorders will find it useful. This volume is yet another small step toward our comprehensive understanding of conversion and its mutations, a phenomenon from the times of Charcot and Freud that is still puzzling us.