Psychogenic and organic movement disorders in children

Functional Tic-Like Behaviors: A Common Comorbidity in Patients with Tourette Syndrome

BACKGROUND

Comorbid functional tic-like behaviors (FTB) have been described only rarely in patients with Tourette syndrome (TS).

OBJECTIVES

We present the first large sample of patients suffering from TS and FTB to raise awareness of this clinical presentation and to guide how to differentiate one from the other.

METHODS

We analyzed clinical data of 71 patients (n = 27 [38.0%] female, mean age: 21.5, range: 11-55) with TS + FTB.

RESULTS

In the majority of patients, FTB started abruptly on average 15 years after tic onset with "treatment-resistant" complex movements and ("coprophenomena-like") vocalizations preceded by timely related psychological stressors. Psychological evaluation revealed evidence for internal conflicts (79%), emotional dysregulation (56%), and maintaining factors (70%). About one third of patients had a positive history for further medically unexplained symptoms. Compared to a large TS sample (n = 1032), patients with TS + FTB were more likely to be female, and presented significantly more common with "coprophenomena-like" symptoms, atypical influential factors, atypical descriptions of premonitory sensations, and higher rates of comorbid obsessive-compulsive disorder and "self-injurious" behavior.

CONCLUSIONS

Based on our data it can be assumed that FTB is a common comorbidity in TS, similar to functional overlay in other movement disorders and epilepsy. Before classifying a patient as suffering from treatment-resistant TS, FTB should be ruled out.

Functional Neurological Disorder-Old Problem New Perspective

Functional neurological disorder (FND) is a common issue in the pediatric population. The concept and our understanding of functional neurological disorders have changed over the past years, and new etiologic models and treatment plans have been explored. Knowledge about FND in the pediatric population, however, is lacking. The aim of this review is to provide an update on pediatric functional neurological disorder. We conducted a literature search of PubMed and SCOPUS databases and reviewed a total of 85 articles to gain insight into the current understanding of FND etiology, diagnosis, treatment, and prognosis in children and adolescents. Functional and high resolution MRI revealed abnormal connectivity and structural changes in patients with functional symptoms. The diagnostic criteria no longer require the presence of a psychological factor and instead focus on a rule-in diagnosis. Treatment of FND includes a clear communication of the diagnosis and the support of a multidisciplinary team. Although FND typically has a poor prognosis, better outcomes appear to have been achieved in children and young adults. We conclude that pediatric functional neurological disorder is a prevalent pathology and that this patient population has additional specific needs compared to the adult population.

The recent surge of functional movement disorders: social distress or greater awareness?

PURPOSE OF REVIEW

To analyze the interrelated factors that have led to the striking increase in functional movement disorders in recent years, with a focus on functional tic-like behaviours (FTLB).

RECENT FINDINGS

The sudden onset of FTLB has been widely observed in several countries since the beginning of the SARS-CoV-2 pandemic, whereas it was previously very rarely reported. Pandemic-related FTLB typically occur in young females, share complex, disabling and tic-lookalike patterns, and are usually triggered by the exposure to videos portraying tic-like behaviours on social media. Both pandemic-related FTLB and prepandemic FTLB are associated with high levels of depression and anxiety. FTLB related to the pandemic highlight the role of social media in the psychopathological behaviours of our time.

SUMMARY

We suggest FTLB are due to a combination of predisposing factors (high genetic and epigenetic risk for anxiety and depression, negative past experiences) and precipitating factors (pandemic and its impact on mental health, exposure to certain social media content). These factors of vulnerability may increase the risk of developing behavioural and emotional problems in youth, such as FTLB. Early diagnosis and appropriate treatment of psychiatric comorbidities seem to be predictors of positive prognosis.

The Rise of Functional Tic-Like Behaviors: What Do the COVID-19 Pandemic and Social Media Have to Do With It? A Narrative Review

BACKGROUND

There has been a rise in explosive onset of tic-like behaviors during the COVID-19 pandemic. Historically, this is an uncommon phenomenology of functional movement disorders across all ages. Both the psychological burden of the pandemic and social media usage have been implicated in the rise of these tic-like behaviors.

METHODS

This paper provides a narrative review of the literature on chronic tic disorders, functional tics, and mass functional illness with particular focus on the key distinguishing features, role of social media, and the role of COVID-19.

RESULTS

The COVID-19 pandemic has profoundly affected the mental health of many individuals, including children, adolescents, and their caregivers. Implementation of lockdowns, lifestyle disruptions, school closures, and social distancing have driven a surge in social media and digital technology use. The combination of predisposing factors, the psychological burden of the COVID-19 pandemic, and social media are implicated in the rise and spread of tic-like behaviors; which may represent a modern-day form of mass functional illness. While many of the features overlap with functional tics, there are emerging distinctive features that are important to recognize. A more encompassing term, Functional Tic-Like Behaviors, is used to better reflect multiple contributing factors.

CONCLUSION

Knowledge of these differences is essential to mitigate downstream health effects and poor outcomes.

Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments

Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive "laboratory-based" testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes.

Functional Movement Disorders in Children

Functional movement disorders (FMDs) are not uncommon in children. The age at onset may have a bearing on the phenomenological pattern of abnormal movement, risk factors, and response to different treatment modalities in this age group. FMDs in children resemble their adult counterparts in terms of gender preponderance, but risk factors are quite different, and often influenced by cultural and demographic background. FMDs contribute to a significant proportion of acute pediatric movement disorder patients seen in emergency settings, ranging from 4.3 to 23% in different case series. The most common movement phenomenologies observed in pediatric FMDs patients are tremor, dystonia, gait disturbances, and functional tics. Various social, physical, and familial precipitating factors have been described. Common social risk factors include divorce of parents, sexual abuse, bullying at school, examination pressure, or other education-related issues, death of a close friend, relative, or family members. Physical trauma like minor head injury, immunization, tooth extraction, and tonsillectomy are also known to precipitate FMDs. The response to treatment appears to be better among pediatric patients. We aim to review FMDs in children to better understand the different aspects of their frequency, clinical features, precipitating factors, diagnosis, treatment, and outcome.

Pediatric Functional Movement Disorders: Experience from a Tertiary Care Centre

Objectives:

Functional movement disorders (FMDs) pose significant diagnostic and management challenges. We aimed to study the socioeconomic and cultural factors, underlying psychopathology and the phenomenology of FMDs in children.

Methods:

The study is a retrospective chart review of 39 children (16 girls and 23 boys) who attended our neurology OPD and the movement disorders clinic at the National Institute of Mental Health and Neurosciences (NIMHANS) between January 2011 and May 2020. The diagnosis of FMD was based on Fahn and Williams criteria and the patients were either diagnosed as “documented” or “clinically established”. All the relevant demographic data including the ethnicity, socioeconomic and cultural background, examination findings, electrophysiological, and other investigations were retrieved from the medical records.

Results:

The mean age at onset was 12.69 ± 3.13 years. Majority of the children were from urban regions (56.41%) and belonging to low socioeconomic status (46.15%). Thirty (76.92%) were found to have a precipitating factor. Myoclonus was the most common phenomenology observed in these patients (30.76%), followed by tremor (20.51%), dystonia (17.94%), and gait abnormality (7.69%). Chorea (5.12%) and tics (2.56%) were uncommon. Tremor (37.5%) and dystonia (18.75%) were more common in girls, whereas myoclonus (39.13%) was more common in boys.

Conclusions:

The symptoms of FMD have great impact on the mental health, social, and academic functioning of children. It is important to identify the precipitating factors and associated psychiatric comorbidities in these children as prompt alleviation of these factors by engaging parents and the child psychiatrist will yield better outcomes.

Psychogenic movement disorders in children and adolescents: an update

This short communication provides an update on childhood psychogenic movement disorders (PMD), focusing on descriptive studies and case reports from 2008 to 2018. Known also as functional movement/motor disorders, PMD diagnoses are relatively common in adults but less so in children. In group studies over the past decade, sample prevalence of childhood PMD ranged from 2.8 to 23.1%, with a higher percentage of girls in most studies (consistent with adult PMD literature). Common types of PMD included tremor (32.4%), dystonia (29.5%), and myoclonus (24.3%). Precipitating events for PMD onset included H1N1 influenza vaccinations, family/child stressors, anxiety/depression in the child or parent, panic attacks, behavior disorders, injury or accident, sexual abuse of the child or family member, death of a close relative, parental discord, domestic violence, school-related problems, medical illness/surgery, sleep disturbance, and participation in competitive sport or dance. The most frequently mentioned treatments were cognitive behavioral therapy, psychotherapy, relaxation techniques, and physiotherapy.Conclusion: Although additional cases of childhood PMD have been published over the past decade, little new information has appeared. There is still no "diagnostic gold standard," making an accurate estimate of prevalence virtually impossible and contributing to confusion among pediatricians when trying to identify children with PMD. What is Known: • Psychogenic movement disorders (PMD) occur in children as well as adults. • The most common types of childhood PMD are tremor, dystonia, and myoclonus. What is New: • The most common childhood PMD treatments were cognitive behavioral therapy, psychotherapy, physiotherapy, and relaxation techniques (2008-2018). • Due to lack of a standardized definition for PMD, confusion exists as to which movement disorders to include. With the inability to reliably diagnose PMD and the ambiguity as to which movement disorders it comprises, it is difficult to determine the most effective treatments.

A 2-Year-Old Girl with Functional Dystonia Manifesting as Forceful Finger Flexion Producing Fixed Posture of Clenched Hands

View Supplementary Video 1

Psychogenic Movement Disorders in Adults and Children: A Clinical and Video Profile of 58 Indian Patients

Background

Psychogenic movement disorders (PMDs) represent 2% to 20% of patients with movement disorders. There is a paucity of literature on PMD in children, with most existing literature relating to adults only.

Methods

For this detailed report of 58 patients (33 adults and 25 children) with PMD, history was assessed in the form of disease onset, duration, precipitating factors, diagnosis, and outcome. Movement phenotype was classified in terms of its appearance as tremor, dystonia, myoclonus, chorea, and others. Clinical evaluations were done to document variability, distractibility, and entrainment. Surface electromyography studies were obtained in patients with tremor.

Results

Seven adults and 7 children were classified with "documented" PMD, and 26 adults and 18 children were classified with "clinically established" PMD. Abrupt onset was common in adults (75.75%) and children (68%). The most common precipitating factors were family and social issues (42.42%) in adults and fear of examination (40%) and school-related issues (24%) in children. Tremor was the most common PMD in both adults and children. The second most common PMD was hemifacial spasm in adults.

Conclusion

The majority of patients had abrupt onset of symptoms, and tremor was the most common form of movement disorder. The second most common PMDs were hemifacial spasm in adults and dystonia and gait abnormality in children. The most common precipitating factors in adults were related to family and social issues; whereas, in children, examination and school-related issues were most common. Complete improvement was seen in only 405 of patients.

Chiropractic Care of a 10-Year-Old Boy With Nonorganic Gait Disorder: A Case Report

OBJECTIVE

The purpose of this case report is to describe the multidisciplinary management of a boy with nonorganic gait disorder.

CLINICAL FEATURES

A 10-year-old boy presented to a chiropractic clinic having had a concussion 1 week prior. He presented with lower limb muscle weakness and ataxia while weight bearing. He was referred immediately to the emergency department, from which he was sent to a neurologist at a children's hospital. The neurologist's diagnosis was nonorganic gait disorder.

INTERVENTION/OUTCOME

Treatment consisted of physiotherapy, occupational therapy, and a psychiatric assessment. Chiropractic care including manipulative therapy was initiated 6 months after diagnosis. After 1 year, the gait disorder was resolved.

CONCLUSION

The addition of chiropractic care to conventional treatment may have been supportive in the recovery process for this patient. The condition required 1 year to resolve, with questions remaining as to whether the symptom resolution was a result of treatment or natural history.

"I swear it is Tourette's!": On functional coprolalia and other tic-like vocalizations

Coprolalia in neuropsychiatry is typically associated with tic disorders, in particular Gilles de la Tourette syndrome. To date, there has been no report of functional coprolalia. Here, we provide the clinical characteristics of 13 adolescent and adult patients with coprolalic and other functional tic-like complex vocalizations who, on the basis of these symptoms, were misdiagnosed with a primary tic disorder, most commonly Gilles de la Tourette syndrome. We describe similarities and highlight the differences from primary tic disorders in order to provide a pragmatic list of clinical clues that will facilitate correct diagnostic labeling and thereby treatment. Finally, we emphasize that the distinction between a primary and a functional tic disorder should rely on a combination of neuropsychiatric symptoms and signs and not on the presence of single, however striking, abnormal behaviors, such as coprolalia.

Recognizing uncommon presentations of psychogenic (functional) movement disorders

BACKGROUND

Psychogenic or functional movement disorders (PMDs) pose a challenge in clinical diagnosis. There are several clues, including sudden onset, incongruous symptoms, distractibility, suggestibility, entrainment of symptoms, and lack of response to otherwise effective pharmacological therapies, that help identify the most common psychogenic movements such as tremor, dystonia, and myoclonus.

METHODS

In this manuscript, we review the frequency, distinct clinical features, functional imaging, and neurophysiological tests that can help in the diagnosis of uncommon presentations of PMDs, such as psychogenic parkinsonism, tics, and chorea; facial, palatal, and ocular movements are also reviewed. In addition, we discuss PMDs at the extremes of age and mass psychogenic illness.

RESULTS

Psychogenic parkinsonism (PP) is observed in less than 10% of the case series about PMDs, with a female-male ratio of roughly 1:1. Lack of amplitude decrement in repetitive movements and of cogwheel rigidity help to differentiate PP from true parkinsonism. Dopamine transporter imaging with photon emission tomography can also help in the diagnostic process. Psychogenic movements resembling tics are reported in about 5% of PMD patients. Lack of transient suppressibility of abnormal movements helps to differentiate them from organic tics. Psychogenic facial movements can present with hemifacial spasm, blepharospasm, and other movements. Some patients with essential palatal tremor have been shown to be psychogenic. Convergence ocular spasm has demonstrated a high specificity for psychogenic movements. PMDs can also present in the context of mass psychogenic illness or at the extremes of age.

DISCUSSION

Clinical features and ancillary studies are helpful in the diagnosis of patients with uncommon presentations of psychogenic movement disorders.

Sleep in psychogenic nonepileptic seizures and related disorders

Psychogenic nonepileptic seizures (PNES), a form of functional neurological symptom disorder (FNSD), are very rarely seen in genuine, electroencephalography (EEG)-confirmed sleep. However, they are more commonly reported as a nocturnal occurrence, likely from a state that is misidentified as sleep (termed by some as "pseudosleep"). Sleep state can be helpful to distinguish FNSD from other neurological disorders. Pseudo-cataplexy, a form of "psychogenic" narcolepsy, "pseudo-parasomnia" and PNES can have a similar presentation. PNES and posttraumatic stress disorder (PTSD) frequently share previously experienced psychological trauma, and therefore the sleep abnormalities found in PTSD may be similarly present in PNES. Future research should use EEG monitoring to evaluate the sleep physiology of patients with FNSD such as PNES, as insights into sleep abnormalities may enable further understanding of the etiology and manifestations of PNES.

The clinical features of psychogenic movement disorders resembling tics

BACKGROUND

Psychogenic movement disorders (PMDs) may be difficult to differentiate from organic abnormal movements.

METHODS

We aimed to characterise the prevalence and clinical features of PMDs resembling tics during the last 3.5 years in our centre.

RESULTS

We studied 9 patients (five females) with psychogenic tics representing 4.9% of all 184 patients first evaluated for a PMD during the study period. The mean age at onset was 34.1 years. Lack of premonitory sensations, absence childhood and family history of tics, inability to suppress the movements and coexistence with other PMDs and pseudoseizures were common in our patients. Compared with 273 patients with Tourette syndrome, those with PMDs resembling tics were older: 36.3 versus 18.7 years (p=0.014) at presentation and more frequently female (p=0.030).

CONCLUSIONS

Movements resembling tics are observed in a small proportion of patients with PMDs. Clinical features can help to differentiate them from organic tics.

Sleep in thyrotoxicosis

OBJECTIVE

Pattern of sleep in hyperthyroid state / thyrotoxicosis has not been systematically studied. It is being characterized as poor without further elaboration. We analyzed the pattern of sleep in a large sample of individuals with thyrotoxicosis who came to our endocrine center in southern India.

MATERIALS AND METHODS

We identified individuals with the diagnosis of 'thyrotoxicosis' from our electronic medical record database, and evaluated clinical parameters and pattern of their sleep: difficulty in falling asleep (DFA), difficulty in maintaining sleep (DMS), excess daytime sleepiness). In the first phase, univariate analysis with logistic regression was performed. Multivariate logistic regression was performed in the next phase on variables with a P-value < 0.1: these were considered as potential categories/ variables.

RESULTS

In model response variable with DFA, multivariate logistic regression predicted that subjects with abnormal appetite (more 1.7 or less 2.2), change in bowel motion (loose 1.5 or constipation 2.8), in mood (easy loss of temper 3.4), change of voice -- hoarse 7.4 or moderately hoarse 3.1), tended to have higher chances of difficulty in falling asleep (DFA). Patients with tremor (yes = 5.4) had greater likelihood of difficulty in maintaining sleep (DMS).

CONCLUSIONS

Individuals with hyperthyroidism/thyrotoxicosis principally had difficulty in falling asleep DFA, which was related to hyperkinetic features.

Schizophrenieforme Symptomatik bei Chorea minor

Die Chorea minor (Sydenham), die häufigste erworbene Ursache für Bewegungsstörungen im Kindesalter, ist gekennzeichnet durch unwillkürliche und abrupte Bewegungsmuster. Bei einem Teil der Patienten treten zusätzlich neuropsychologische Dysfunktionen und psychiatrische Störungsbilder wie Angst-, Zwangs-, und Tic-Störungen auf. Psychotische Symptome wurden dabei bisher nur selten beschrieben (n = 4, davon zwei Fallberichte sowie eine prospektive und eine retrospektive Studie). Wir berichten von einer 12-jährigen Patientin mit akuter paranoid-halluzinatorischer Symptomatik und choreatiformer Bewegungsstörung. Die Kombination der im Hinblick auf die paranoid-halluzinatorische Symptomatik wirksamen antipsychotischen Therapie mit hochdosiertem Prednisolon verbesserte die weiterbestehende Negativ-Symptomatik und führte zu einer vollständigen Remission der Bewegungsstörung. Nach Reduktion der Steroide traten eine Verschlechterung der Negativ-Symptomatik und ein Rezidiv der Bewegungsstörung ein. Ursächlich für die Schizophrenie wird eine Funktionsstörung des Corpus Striatum vermutet, welche sekundär das Arbeitsgedächtnis und den für kognitive Flexibilität bedeutsamen präfrontalen Kortex beeinträchtigt. Als Ursache der Chorea minor gilt eine postinfektiöse autoimmun-mediierte Störung der Basalganglienfunktion, ausgelöst durch einen vorausgegangenen Streptokokken-Infekt. Der Morbus Huntington und der Morbus Wilson sind Bewegungsstörungen, die auf einer Basalgangliendysfunktion beruhen und zudem häufig mit psychotischen Symptomen assoziiert sind. Ähnlich könnte die Kombination aus psychotischer und choreatiformer Symptomatik unserer Patientin auf einer Basalgangliendysfunktion beruhen. Die Negativ-Symptomatik wäre durch eine sekundäre Störung präfrontal kortikaler Strukturen erklärbar.

Psychogenic movement disorders in children

Psychogenic movement disorders (PMDs) are well characterized in adults, but childhood-onset PMDs have not been extensively studied. We reviewed the medical records of children who were diagnosed in our clinic with PMDs since 1988 and identified 54 patients with PMDs, representing 3.1% of our pediatric movement disorder population and 5.7% of all PMD cases. The mean age at symptom onset was 14.2 years (+/-2.11, range 7.6-17.7). Similar to published data in adults, two-thirds of children exhibited multiple PMD phenotypes, the most common being tremor followed by dystonia and myoclonus. Most PMDs were abrupt in onset, paroxysmal and triggered by identifiable physical or psychological trauma. As in adults, childhood PMDs were more likely to affect females, but there was no female predominance in children less than 13 years old. Although prior studies suggest that medically unexplained symptoms beginning in childhood often follow a benign course, this cohort of children experienced marked disability and morbidity related to PMDs, including prolonged school absences and unnecessary surgical procedures in more than one-fifth of patients.

Psychogenic movement disorders in children: a report of 15 cases and a review of the literature

Data on psychogenic movement disorders (PMD) in children are scarce, with most existing literature relating to adults only. We report 15 cases with the aim of highlighting the clinical characteristics, risk factors, comorbidity, treatment, outcome, and prognosis of PMD in children. Only 13% of cases had onset before age 10, with the mean age at onset being 12.3 years. Females were predominantly affected (F:M = 4:1). The most common types of movement disorders seen were dystonia (47%), tremor (40%), and gait disorders (13%). Multiple hyperkinetic phenomenologies were observed in many cases. Abrupt onset and precipitation by minor injuries, and stressful life events were commonly reported. Clinical clues on examination suggesting a psychogenic origin were similar to those identified in adults. A distinct feature of PMD in children was the predominant involvement of the dominant limb. The underlying psychiatric diagnosis was conversion disorder in the majority of cases. Time from symptom onset until diagnosis of a PMD varied broadly (between 2 weeks and 5 years). Treatment with cognitive and behavioral therapy and rehabilitation by a multidisciplinary team led to improvement in most cases. However, treatment was much more effective in children with a short time from symptom onset to diagnosis and treatment.