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Comment on Psychogenic Versus Functional Movement Disorders We read with great interest the recent viewpoints of Drs. Edwards, Stone, and Lang and Drs. Fahn and Olanow on appropriate terminology of psychogenic versus functional movement disorders.1,2 Obviously what they write carries a lot of weight and hence it is important to enter this debate, as we do think that different opinions need also to be voiced. We understand that the use of the term psychogenic in movement disorders has been indeed critical for the distinction of different conditions, particularly dystonia, in the era in which knowledge about phenomenology and pathophysiology was fragmented, and clear terminological division was necessary to prevent misdiagnoses. However, we do believe it is difficult to reconcile the contemporary use of this term with advances in basic neuroscientific and clinical knowledge. Despite being loosely defined,3 the term psychogenic in movement disorders refers to a presumed causal relation between psycho(patho)logical factors and the generation of abnormal movements. However, the psychopathological profiles of patients with psychogenic/functional movement disorders are broadly similar to those of patients with organic movement disorders or healthy controls.4 It is inherently paradoxical for neurologists to label patients as psychogenic without though being able to diagnose psychogenicity and/or even more explain its role in generation of symptoms, and thus, deferring responsibility to a different discipline. In fact, even if neurologists were convinced of doing so, the called-upon psychiatry experts would not use psychogenicity as a prerequisite for diagnosing conversion disorder (or functional neurological symptom disorder) according to the criteria of the latest Diagnostic and Statistical Manual of Mental Disorders version.5 Also, as previously highlighted, the term psychogenic propagates the dualistic distinction of the mind from the brain.1 This conceptual dichotomy creates confusion and disciplinary division, rather than the much-needed synergy of expertise across neurologists, psychiatrists, psychologists, and rehabilitation specialists to treat patients with such disorders. We agree that the term functional is not optimal and merits greater precision in its application.6 Indeed, most contem-

ARTICLES

porary clinical literature, including our own, uses the terms functional and psychogenic interchangeably. We also recognize that the application of either of the two terms may differ between languages. However, the use of the term functional to define a syndrome without etiological inferences but taking into account different factors, including physical contributors7 and signs,8 is, we believe, a more scientific approach and stimulates a true bio-psycho-social approach to research.1 It also leaves space for the much-needed patient acceptance9 and thus leads the way for improved engagement with treatment. Christos Ganos, MD,1,2 Roberto Erro, MD,1 Kailash P. Bhatia, MD,1 and Michele Tinazzi, MD3 1 Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom 2 Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany 3 Department of Neurological and Movement Sciences, University of Verona, Verona, Italy

References 1.

Edwards MJ, Stone J, Lang AE. From psychogenic movement disorder to functional movement disorder: it’s time to change the name. Mov Disord 2014;29:849-852.

2.

Fahn S, Olanow CW. “Psychogenic movement disorders”: they are what they are. Mov Disord 2014;29:853-856.

3.

Lewis A. ’Psychogenic’: a word and its mutations. Psychol Med 1972;2:209-215.

4.

Kranick S, Ekanayake V, Martinez V, Ameli R, Hallett M, Voon V. Psychopathology and psychogenic movement disorders. Mov Disord 2011;26:1844-1850.

5.

American Psychiatric Association. Diagnostic and statistical manual of mental health disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Publishing, 2013.

6.

Pritchard EA. The functional symptoms of organic disease of the brain. Lancet 1955;268:363-366.

7.

Parees I, Kojovic M, Pires C, et al. Physical precipitating factors in functional movement disorders. J Neurol Sci 2014;338:174-177.

8.

Stone J, Edwards M. Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs. Neurology 2012;79:282-284.

9.

Stone J, Wojcik W, Durrance D, et al. What should we say to patients with symptoms unexplained by disease? The "number needed to offend." BMJ 2002;325:1449-1450.

-----------------------------------------------------------*Correspondence to: Dr. Christos Ganos, Clinical Movement Disorders Group, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom, E-mail: [email protected]

Relevant conflicts of interest/financial disclosures: Nothing to report. Full financial disclosures and author roles may be found in the online version of this article. Received: 21 June 2014; Accepted: 24 August 2014 Published online 24 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.26038

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Functional/Psychogenic Movement Disorders: Do We Know What They Are? Fahn and Olanow’s viewpoint article1 in response to our original paper2 argues for the retention of the term psychogenic on the basis, among other points, that “they are what they are.”

L E T T E R S :

We are concerned first by the assumption that “the psychiatrist has the important roles of finding the psychodynamic conflicts and correcting them,” suggesting that they believe all patients have such conflicts even if they are unaware of them. This approach risks the situation in which patients are told that they must be repressing childhood trauma or other traumatic events if they cannot recall factors thought to be of etiological importance. This is not only potentially punitive to the patient but is unsupported by epidemiological data regarding the role of stress and has a circular logic that is scientifically unfalsifiable. Second, their argument suggests that we “know what they are” and that there is no role, and never will be, for biological factors or a perspective from brain science, in understanding these disorders. We would not suggest that “Parkinson’s disease is a disorder due to getting older” and “Stroke is a disorder due to smoking,” because although both statements are true, they are only true in part. We believe that with regard to psychogenic movement disorder/ functional movement disorder (PMD/FMD) we should be equally humble and appreciate that one specific etiological factor is unlikely to provide a satisfactory explanation for all patients. Third, their arguments suggest that not only do we know what they are, but we also know that the treatment is psychological as well. They argue that avoiding a “psychogenic” diagnosis could mean that the patient does not access psychological treatment. This rather assumes that the best treatments are psychological. In a subset of patients with functional motor symptoms, our experience and that of others, including a positive randomized trial,3 indicates that specialist physiotherapy can be a useful tool in producing long-term benefit without an extensive exploration of associated psychological factors. One could equally argue that a psychogenic diagnosis delays or prevents patients accessing physical treatments like this. In a wider sense, if neurologists continue to see these patients as a purely “psychogenic” problem they may be forgiven for thinking that the patients are in the wrong specialty and should be ejected as soon as possible. Finally, the term psychogenic suggests a dualist view that there is a separate entity called “the mind” from which these symptoms arise. If there is no separate “mind,” then it makes no sense to have debates about whether conditions are “of the mind” or not. Society is in many respects, dualist in outlook, but is it right that those of us in clinical neuroscience specialties should remain so? Functional neurological symptoms have an important psychological dimension, and many patients gain benefit from understanding this and from treatments that are directed toward this perspective. However, the term psychogenic sug-

-----------------------------------------------------------*Correspondence to: Dr. Mark Edwards, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK, E-mail: [email protected]

Relevant conflicts of interest/financial disclosures: Nothing to report. Full financial disclosures and author roles may be found in the online version of this article. Received: 16 June 2014; Revised: 29 June 2014; Accepted: 24 August 2014 Published online 6 October 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.26039

P U B L I S H E D

A R T I C L E S

gests a one-dimensional etiology, diagnostic explanation, and treatment approach that we believe ignores the complexity of the brain and the multiplicity of potential treatments. Is functional a perfect term? No. Is a sympathetic and engaged approach to diagnosis, explanation, and management, which is echoed in Fahn and Olanow’s article, more important than the diagnostic term used? Yes. Fahn and Olanow have confidence that PMDs “are what they are.” We are not so sure that we do fully understand their etiology and mechanism even if we can make a diagnosis from the end of the bed. However, we do have more confidence that the term psychogenic, and the concepts it represents, is one factor that holds back progress in research and patient care in an area acknowledged by all to be a major cause of disability. Mark J. Edwards, PhD,1 Jon Stone, PhD,2 and Anthony E. Lang, MD3 1 Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, UCL, Queen Square, London, United Kingdom 2 Department of Clinical Neurosciences, Western General Hospital, Edinburgh, United Kingdom 3 Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital, Toronto, Ontario, Canada

References 1.

Fahn S, Olanow CW. “Psychogenic movement disorders”: they are what they are. Mov Disord 2014;29:853-856.

2.

Edwards MJ, Stone J, Lang AE. From psychogenic movement disorder to functional movement disorder: it’s time to change the name. Mov Disord 2014;29:849-852.

3.

Jordbru AA, Smedstad LM, Klungsøyr O, Martinsen EW. Psychogenic gait disorder: a randomized controlled trial of physical rehabilitation with one-year follow-up. J Rehabil Med 2014;46:181-187.

“Psychogenic” Versus “Functional” Movement Disorders? That Is the Question I read the two articles addressing the various merits and limitations of terminology of “psychogenic” versus “functional” disorders.1,2 This was one of the topics discussed extensively during the first and second international symposia on “Psychogenic Movement Disorders” held in October 2003 in Atlanta, Georgia, and in April 2009 in Washington, DC. As a result of general consensus by the participants, the term “Psychogenic Movement Disorders” was also used in the title of the two books3,4 that served to summarize the numerous presentations by neurologists, psychiatrists, psychologists, physiologists, and other internationally recognized experts. In the Preface to the second

Movement Disorders, Vol. 29, No. 13, 2014

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psychogenic movement disorders: do we know what they are?

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