Psychogenic Movement Disorders
Posted by anjasmith on November 11, 2007
Everybody who has watched shows about doctors and hospitals has at least once come across the famous Münchausen syndrome.
A psychiatric disorder where the patient basically fakes his/her symptoms in order to be admitted to hospital, maybe makes this one of the most interesting disorders and therefore no wonder why it is used in medical TV shows (no wonder as to why I am writing about it now).
The first time it actually grabbed my attention was when I happened to watch my first and only episode of Grey’s Anatomy. I can’t remember the exact episode, but there was a female patient who was a neuropharmacology expert thingie (not sure about that term), who took a substance Amytriptyline Hydrochloride (a tricylclic anti-depressant drug) in order to apparently induce an adverse side effect: Ventricular Fibrillation. She was diagnosed with Münchausen syndrome. Now what furthermore aroused my curiosity was that they found proof that the attack was induced when her urine was found to be blue.
Now HOLD it there…
blue urine…tricyclics? Ventricular Fibrillation? Well, obviously, those things do not all add up, as we all know and love TV, the things they show us should be administered with a proper dose of table salt (I prefer NaCl 0,9 % sterile…but it’s a matter of taste in humour).
As it turned out, I searched the beloved Web high and low for more information on that episode, and finally found what I was looking for here, but I am not sure myself how reliable that information is….
Anyway, there are certain substances that turn urine different colours, like some tuberculosis antibiotics, and methylene blue, but not tricyclic anti-depressants. According to my donated BNF 2005, serious side effects of that particular anti depressant can cause sudden cardiac death, in overdoses…but no mention of blue urine (how disappointing).
I then turned to the next item on my ‘research list’ which was Münchausen syndrome. Wikipedia had some rather useful info in layman’s terms, which sufficed for quick orientation. What brought me back to this subject though was this very interesting case that I met at my favourite ward (a neurological ward in the university hospital) when I was filling in an evening shift:
A young patient was exhibiting weird ataxic-seizure like attacks involving only the torso, had paraparesis (could not walk) in the lower extremities and lower back pain. During the evening shift report, the physiotherapist gave her evaluation, which coincided with the nurse’s suspicions: The symptoms were probably being faked.
The reason they believed so was that the attacks could not be linked any organic findings (deep tendon reflexes ok, no signs in MRI scans), and the symptoms were not consistent.
That was when I dug into my brain-pockets to recollect my recently acquired knowledge in Münchausen syndrome.
I suggested to my colleague that the patient’s symptoms and behaviour might be related to the above mentioned syndrome. She agreed and further mentioned that she has seen epileptic patients faking grand mal seizures, which is called somatoform disorder, or conversion disorder, where the mind can induce real symptoms.
We decided to consult Ovid, and I typed in the keywords ‘Neurology’ and ‘Munchausen syndrome’, I combined the searches with ‘AND’, and I think I got something like 10 articles. I managed to print out a few abstracts that included an article ‘is that patient faking it?’, unfortunately I can’t find the full references to those articles anymore, I think I gave the printout to my colleague.
However, I later did the same search in Pubmed, and I found some very interesting articles, that I thought very useful: ‘Psychogenic movement disorders’ and ‘Neurological syndromes in factitious disorder’. The former was actually a literature review, and the latter a quantitative study of the frequency of the occurrence of factitious disorder in one particular hospital’s department of neurology (Freie Universität Berlin). Now, I am no expert (yet) in research articles, so I would not recommend taking every word and every finding I read as the absolute truth, but I think that these articles gave me a clearer understanding of how the disorder works, and how to recognize it. References for these articles and further definitions can be found here.
What I was more concerned with, was how do we, as Nurses, recognize and treat this group of disorders? It is very rare, but when it does show up, causes pure mayhem and because of unnecessary invasive tests and other diagnostic techniques, becomes a costly game.
When I observed this young patient, it occurred to me that there is probably a reason why he/she is doing this; that if I present an attitude of ‘oh stop being a nuisance, you are just faking it’, will only create mistrust and frustration, and will not help anyone. Probably, the attacks are real, and the pain is real, to the patient.
I was wondering, how should I confront the patient, so that I can be supportive yet not encouraging the symptoms, and gain the patients trust, so that I can get to the bottom of this?
Not very easy at all.
I have not had any shifts since, at that ward, so I don’t know what happened. But it left me wondering what I could have done more, or said, to help the patient and the doctors to get closer to the answer.
I will do more digging in Ovid, and hopefully I will find some articles or information that deals with the nursing side.
For now…I should really start reading for my research and development exam next week. And then surgical nursing, and then medical equipment, and then neurology, and then drug and pain management, and then anaesthesiology, and then geriatrics…and then I fly to South Africa!
Health tip: Drinking large amounts of caffeine after sleeping only a few hours the night before does not increase concentration levels during exam writing.
Update: I found out a few months later that the patient was diagnosed with a Psychosomatoform syndrome.
christy said
You should be very careful when dealing with patients with that have a diagnosis of any neurological psychogenic disorder esp. movement disorders. Because so many of these disorders have no known cause, being a neurologically involved disorder are prone to flux in direct relation to physical and emotional stress ( because they are often worsened by an increase in oxidative stress on the brain which is directly and sharply increased under stress). Many types of parkinsonism (idiopatic and genetic) have no known cause- many of the genetic causes are yet to be discovered. This is true of many Ataxic syndromes, dystonic, and rare metabolic diseases such as MERRF type disorders. There are over 200 types of neuro-metabolic disorders which can manifest with overlapping symptoms of other metabolic disorders of which the large majority of these have not been identified. There is allot of gray area out there and it is always best to err on the side of caution. New information and research findings may go 1,2,3 years before they are published and who knows how long before it is available to the general public. Some research is never published and only available to those professionals that are privy to that specialties closed pool of new knowledge. Allot of if not the majority of people that have a dx of a neuro-psychogenic disorder and this is especially true of movement disorders go on years down the line to receive an organic diagnosis. The emotional pain and years waisted on expensive psychiatric care are inexcusable and incalcuable. A psychogenic diagnosis should always be a diagnosis of exclusion or very last resort. We are all people and a large precentage of us come from difficult back grounds and it has been shown that patients that do have a HX of mental illness or family issues will more readily volunteer a psychological explanation for their symptoms when a physician is probing for it. Thus it pre-disposes this population to a higher incidence of psychogenic diagnosis or mis-diagnosis. Yet at the same time this population does have a slightly higher incidence of psychogenic disorder. Remember that neurology currently is expanding its discoveries faster than it has in centuries with the help of new technologies and genetic analysis. Psychiatry and Neurology are expected to eventually merge into a single cohesive field of practice. During deep brain stimulation neuro-surgeons have recently discovered that it can resolve the symptoms of obsessive compulsive disorder, Bipolar disorder is expected to be fixed in-utero through fetal genetic manipulation in the next 15 years. Yes Bipolar disorder has a genetic cause that typically skips a generation and hits each affected generation earlier and harder because the mutation grows longer each time it is copied. In addition the first signs of many neurological disorder are psychiatric. Depression and anxiety is often the first sign of Parkinson’s because Parkinson’s and most neurological disorder involve an entire zoo of neurotransmitters including neurepinephrine, seretonin, oxytocin, dopamine, etc. To any clinician especially if the person is referred to psych services first a slight tremor at rest, kinetic, or postural tremor, slowness, fatigue etc could seem to stem from the initial psychological pathology and in fact could very well be co-morbid. – Because all of these chemicals affect mood regulation and movement. For example a person may be on effective treatment for their tremor with L-dopa (parkinsons) or Zonegran (parkinsons) or Inderall (Essential Tremor) which completely resolves the symptoms. Yet none of these treat the chemicals dominantly involved in anxiety or depression -so upon neurological examination if a person is nervous they may display all of the criteria for a psychogenic diagnosis. This could apply to increased tone, and increased dytonic contraction in response to emotional stress. Does this mean that the underlying organic pathology is a non-entity. No. It means that the neurological pathology of the disease is more involved and is the tangled web of neuro-chemistry is often diagnostically over simplified. Sometimes a psychogenic diagnosis which is more common in women than in men is due to the lack of neuro-hormone and endocrine knowledge of the neurologist or clinician. For example in a neurological exam – esp from a movement disorder specialist evaluating primitive reflexes and proprioception is of cardinal importance because a positive finding of any of these means serious illness – too often a serious degenerative illness. A woman may have a strongly positive startle response at the time of the month her estrogen levels are highest, as well many of her reflexes may be more reactive etc. Now if I were a clinician assessing a woman with a positive psych history, with symptoms of a movement disorder, and on one visit she had a strong startle response and on another she didn’t, and then on another she did——-chart inconsistencies are a criteria for psychogenic diagnosis’. I would be tempted to start looking for any psychological explanations or contributing factors to her symptoms especially with her contributing psychological history. Yet I have never met a neurologist (and I’ve interacted with allot of them) that takes a detailed history of a womans menses or asks her where she is in her cycle to get a rough estimate of what her neuro-hormone levels might be and how that might affect his or her assessment. Basically I believe that syndromes like Munchausen, conversion disorder, psychogenic disorder. Should be assessed as a very last resort and with more than 3 consulting experts in the relative fields of possible pathology, in addition to receiving a 2nd and if it is a serious diagnosis 3rd opinion. In the end the focus of medicine is the patient. So “waisting time” on countless tests that in all reality nobody knows if it will prove useful or diagnostic should not ever be a consideration. The most amount of damage is done to the patient when R/O a psychogenic diagnosis if the true diagnosis is missed simply because All other possibilities were not investigated. Not the other way around.
anjasmith said
Hi Christy,
Thank you for your comment on my post, and for the extensive information.
Indeed, I share the same opinion on patients that exhibit psychogenic symptoms. That is the reason I wrote the post, because as you imply, it is indeed not simple
.
I still believe, though I am no expert and my opinion carries the least weight in the world of medicine, that even if the diagnosis is still open or undefined and if there is even a probable chance that a certain patient with symptoms of movement disorder that is suspected to be psychogenic might actually be somatic in origin, the patient could still benefit greatly from psychotherapy.
As you stated yourself, we all have problems, and have had to deal with traumas and difficulties. No human walks on this planet without his/her fair share of wounds. Psychiatry is a valuable tool that can help anyone, also patients with true somatic diseases, to cope with underlying stress, problems and pain.
I have just completed six wonderful weeks at an open psychiatric ward where we had quite a few patients that suffered from somatoform and psychogenic problems. I can assure you that at least in Finnish psychiatric wards, such a patient is treated with utmost care and every physical symptom whether visible or not is investigated and treated somatically. I find, and many psychiatrists are of the same opinion, that patients with suspected psychogenic disorders recieve much better care in psychiatry than in somatic wards, simply due to the fact that they are more often than not taken seriously.
On somatic wards, there is very little time to tend to the psychological needs of patients, and sadly very serious conditions such as depression and anxiety go unnoticed or untreated (before a nurse shoots me, may I say that this may not always be the case, but very understandably overlooked due to priority settings).
that is my short reply to this. This is a very relevant issue in health care, and quite extensive, so one can debate on this for ever.
Lastly, I would like to say that I take everything a patient says seriously. All patients have a right to be heard, no matter how demented or otherwise handicapped they may seem. Nevertheless, I also try to set boundaries, and support mental health as well as physical health. There is a fine line between health and sickness, especially on the mental side. Also there is an even finer line between mental and somatic disease. And so I take your advice to be careful into consideration.
Best regards,
Anja.