Movement Disorders VOI. 7, NO. 4, 1992, pp. 333-338. 0 1992 Movement Disorder Society
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SUPREMEKI
Noise-Induced Psychogenic Tremor Associated with Post-traumatic Stress Disorder Arthur S. Walters and Wayne A. Hening Movement Disorder Group, Department of Neurology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, and Neurology Service, V A Medical Center, Lyons, New Jersey, U.S.A.
Summary: Tremors in post-traumatic stress disorders have not been previously well characterized. A 67-year-old man has a 46-year history of a noiseinduced exaggerated startle reflex followed by a large amplitude rest, postural and kinetic tremor that may persist for up to 3 days. This tremor is superimposed on a continuous mild organic postural/kinetic tremor whose electrophysiological characteristics are different from those of the overlying tremor. We attribute the exaggerated startle reflex and the noise-induced tremor to PostTraumatic Stress Disorder (PTSD) and postulate a psychogenic origin for the noise-induced tremor. The patient also believes the noise-induced tremor to be psychologically based and to be produced by the fear and anxiety he experiences when he hears loud, unexpected noises. The sudden onset of the noiseinduced tremor, its intermittent character, its temporary disappearance on distraction despite the patient's inability to suppress it, inconsistencies in handwriting and figure drawing, and the fact that the noise-induced tremor is stimulus specific and persists long after the offending stimulus (noise) is no longer present all suggest a tremor of psychogenic origin. Key Words: Tremor-Post-traumatic stress disorder.
genic (7); although hysterics may sometimes entertain a psychological cause for their movement disorder, this is not the usual case ( 1 4 ) . (c) Patients with real movement disorders usually affirm that they are distressed by their physical disability and that psychological factors can make their movement disorder worse, as when patients with Parkinson's disease or physiological or essential tremor have a worsening of their tremor when they feel anxious in the physician's office. (d) In contrast to patients with real movement disorders, those with conversion hysteria have classically been thought to be indifferent to their symptoms. However, it has recently been pointed out that this is not universally true (6). We now report a patient in which a tremor that we think is psychogenic is also thought by the patient to be psychologically based. Feelings of fear and anxiety accompany the tremor. The tremor is also stimulus specific, as it is precipitated by noise;
Movement disorders can be influenced by and in turn can influence an emotional conflict or state (19): (a) Patients with a real, undiagnosed, organically based movement disorder will sometimes wishfully suggest to the clinician that the movement disorder is psychologically based. (b) Malingerers are motivated by financial gain or may get some emotional gain by consciously faking a movement disorder (7). Patients with conversion hysteria deal with unappreciated and unresolved emotional conflict by unconsciously faking a movement disorder (1-6), e.g., parkinsonism, myoclonus, dystonia, or tremor (15 ) . In contrast to patients with real movement disorders, those who are malingering virtually never state that their movement disorders are psycho Videotape segments accompany this article. Address correspondence and reprint requests to Dr. A. S . Walters at Department of Neurology CN 19, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903-0019, U.S.A.
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we attribute it to Post-Traumatic Stress Disorder (PTSD). Tremors have been previously described as a consequence of emotional stress (8,9), but to our knowledge they have not been previously characterized clinically or electrophy siologically.
CASE REPORT On January 4th, 1944, the patient, then a 21-yearold seaman, set sail from Staten Island, New York on a Navy escort ship bound for Guantanamo Bay, Cuba. Six hours out to sea his vessel, the U.S.S. Saint Augustine, was accidentally struck by a merchant marine ship. The Saint Augustine sank in 5 min, with loss of life to all but 29 of the 145 crew members. Immediately after being rescued, the sailor noticed the onset of an intermittent tremor that has persisted to this day and is reevoked by loud noise. He describes his ordeal in particularly tragic terms and he attributes his tremor to that ordeal. He changed his peace-time profession because of noise levels and is still vigilant to avoid loud
noises. When the patient has the tremor, he experiences a fear similar to that which he had when his ship sank. He has recurrent distressing dreams of the sinking of the ship, but these have decreased in recent years. He deliberately avoids any thought of the ship sinking, and ever since the sinking has been unable to watch a war movie or a mystery thriller without breaking out in a sweat. After the sinking of the ship, the patient became depressed and disinterested in his previous hobbies, such as fishing. He has been married and divorced three times. This patient meets the criteria for PTSD (Criteria A; B1, 2, 3, 4; C1, 2, 4; D4, 5 , 6; and E) (Table 1) (10). The patient drank heavily between 1955 and 1975, and then stopped. He is unsure whether alcohol abated the noise-induced tremor. In 1964, he contracted pneumonia while building highways in California. A diagnosis of San Jauquin Valley Fever was made, with subsequent left lower lobe pneumonectomy. The patient continued to be a four pack per day smoker and was later diagnosed with
TABLE 1. Diagnostic criteria for post-traumatic stress disorder ~
"A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone (e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence). B. The traumatic event is persistently reexperienced in at least one of the following ways: "1. Recurrent and intrusive distressing recollections of the event (In young children, repetitive play in which themes or aspects of the trauma are expressed) "2. Recurrent distressing dreams of the event "3. Sudden acting or feeling as if the traumatic event were recurring [includes a sense of reliving the experience, illusions, hallucinations, and dissociative (flashback) episodes, even those that occur upon awakening or when intoxicated] "4. Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma. C . Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: "1. Efforts to avoid thoughts or feelings associated with the trauma "2. Efforts to avoid activities or situations that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma (psychogenic amnesia) "4. Markedly diminished interest in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills) 5 . Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a long life). D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following: 1 . Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating "4. Hypervigilance " 5 . Exaggerated startle response "6. Physiologic reactivity on exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator). "E. Duration of the disturbance (symptoms in B, C, and D) of at least 1 month. Specify delayed onset if the onset of symptoms was at least 6 months after the trauma. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Copyright 1987, American Psychiatric Association. Criteria pertinent to patient. See text for details.
Movement Disorders, Val. 7, No. 4, 1992
NOISE-INDUCED PSYCHOGENIC TREMOR
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FIG. 1. Patient’s handwriting before startle.
chronic obstructive pulmonary disease, for which he continues to take bronchodilators. At least 12 years after the sinking of the ship he noticed a continuous finer tremor. As far as he knows neither his parents nor any of his seven siblings ever had tremor. On examination the patient shows no signs of Parkinsonism. Prior to startle he displays a continuous smaller amplitude, and primarily postural/ kinetic tremor (see videotape). With very loud unexpected noises he has an exaggerated startle reaction (see videotape), followed by a much larger amplitude tremor that is prominent at rest, as well as during sustained posture and during action (see videotape). Although one loud noise can cause the larger amplitude, startle-induced tremor to last for several minutes, repeated loud noises over a few minutes can cause it to last for several days (see videotape) and then disappear (see videotape). Sometimes several days pass before a noise is loud and unexpected enough to again induce the larger amplitude tremor. Nonetheless, after the induction of this tremor, any unexpected noise, even a normal speaking voice from behind, may cause the patient to jump. Once evoked, the larger amplitude, noiseinduced tremor is continuous until it ceases. When asked to voluntarily suppress the tremor, the patient cannot do so (see videotape). However, when the patient is distracted, the larger amplitude, noiseinduced tremor temporarily disappears (see videotape). The patient’s handwriting is of moderate size
\
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FIG. 2. Patient’s handwriting after startle.
FIG. 3. Circle drawn after startle.
and shows only minimal evidence of postural/ kinetic tremor at baseline (Fig. 1). After startle, the handwriting is much bigger and sometimes shows gross and sometimes minimal evidence of postural/ kinetic tremor (Fig. 2). After startle, a perfectly round circle has uniform waviness at the edges in the manner of the figures drawn by patients with psychogenic tremor, as depicted by Koller et al. (Fig. 3) (5). A CAT scan of the brain was negative in 1989. ELECTROPHYSIOLOGICAL METHODS Startle was studied through repetitive 105 dB 1 kHz tones with a 0.1 ms rise time and 10 ms plateau presented through headphones to both ears simultaneously. Recordings were made from the orbiculark oculi, mastoid, sternocleidomastoid, biceps, and anterior tibialis muscles. EEG and head movement were also monitored. One-second epochs were collected after each stimulus with a Pathfinder I1 (Nicolet, Madison, WI) clinical averaging system that sampled all channels once every millisecond. Stimuli were delivered in five blocks of four tones. The first block had an approximate inter-tone interval (ITI) of 5 min, while each successive block had a 1 min shorter IT1 (from second block, IT1 = 4 min to fifth block, IT1 = 1 min). Blocks were separated by a 5-min rest period. Records were reviewed offline, and latency and duration of electromyography
Movement Disorders, Vol. 7, No. 4, 1992
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A . S. WALTERS AND W. A . HENING
(EMG) responses were determined with cursors. The EMG was full-wave rectified and integrated to obtain an integrated EMG (IEMG) value. EMG duration and IEMG were averaged by block. Habituation across blocks was scored as the percentage decrease in average EMG duration and IEMG compared to the average obtained for each subject in the first block. The patient was compared to a series of normal subjects (11,12). The patient's tremors were also studied during various activities with surface EMG of bilateral wrist flexors and extensors, and right arm biceps, triceps, and abductor pollicis brevis (APB). Accelerometry was performed on both hands. Records were sampled and inspected to determine tremor amplitude, frequency, and pattern. Tremor frequency was confirmed by spectral analysis of 2.56-s segments of EMG and accelerometry records.
RESULTS The patient shows a classical startle with rostrocaudal progression of involved muscles from the orbicularis oculi down the neuraxis to the limbs (See Fig. 4A to show involvement of the right arm). He showed great resistance to habituation of muscle responses (11,12). Latencies of muscle responses to loud clicks were otherwise within the normal range. Normal subjects showed decreases of >30% in EMG response duration and a 40% decrease in IEMG in the orbicularis oculi by the fourth block of stimuli (IT1 = 2 min). The patient showed no decrease in duration and
"WE0
SUPREMEKI
Noise-Induced Psychogenic Tremor Associated with Post-traumatic Stress Disorder Arthur S. Walters and Wayne A. Hening Movement Disorder Group, Department of Neurology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, and Neurology Service, V A Medical Center, Lyons, New Jersey, U.S.A.
Summary: Tremors in post-traumatic stress disorders have not been previously well characterized. A 67-year-old man has a 46-year history of a noiseinduced exaggerated startle reflex followed by a large amplitude rest, postural and kinetic tremor that may persist for up to 3 days. This tremor is superimposed on a continuous mild organic postural/kinetic tremor whose electrophysiological characteristics are different from those of the overlying tremor. We attribute the exaggerated startle reflex and the noise-induced tremor to PostTraumatic Stress Disorder (PTSD) and postulate a psychogenic origin for the noise-induced tremor. The patient also believes the noise-induced tremor to be psychologically based and to be produced by the fear and anxiety he experiences when he hears loud, unexpected noises. The sudden onset of the noiseinduced tremor, its intermittent character, its temporary disappearance on distraction despite the patient's inability to suppress it, inconsistencies in handwriting and figure drawing, and the fact that the noise-induced tremor is stimulus specific and persists long after the offending stimulus (noise) is no longer present all suggest a tremor of psychogenic origin. Key Words: Tremor-Post-traumatic stress disorder.
genic (7); although hysterics may sometimes entertain a psychological cause for their movement disorder, this is not the usual case ( 1 4 ) . (c) Patients with real movement disorders usually affirm that they are distressed by their physical disability and that psychological factors can make their movement disorder worse, as when patients with Parkinson's disease or physiological or essential tremor have a worsening of their tremor when they feel anxious in the physician's office. (d) In contrast to patients with real movement disorders, those with conversion hysteria have classically been thought to be indifferent to their symptoms. However, it has recently been pointed out that this is not universally true (6). We now report a patient in which a tremor that we think is psychogenic is also thought by the patient to be psychologically based. Feelings of fear and anxiety accompany the tremor. The tremor is also stimulus specific, as it is precipitated by noise;
Movement disorders can be influenced by and in turn can influence an emotional conflict or state (19): (a) Patients with a real, undiagnosed, organically based movement disorder will sometimes wishfully suggest to the clinician that the movement disorder is psychologically based. (b) Malingerers are motivated by financial gain or may get some emotional gain by consciously faking a movement disorder (7). Patients with conversion hysteria deal with unappreciated and unresolved emotional conflict by unconsciously faking a movement disorder (1-6), e.g., parkinsonism, myoclonus, dystonia, or tremor (15 ) . In contrast to patients with real movement disorders, those who are malingering virtually never state that their movement disorders are psycho Videotape segments accompany this article. Address correspondence and reprint requests to Dr. A. S . Walters at Department of Neurology CN 19, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903-0019, U.S.A.
333
334
A . S . WALTERS AND W . A . HENING
we attribute it to Post-Traumatic Stress Disorder (PTSD). Tremors have been previously described as a consequence of emotional stress (8,9), but to our knowledge they have not been previously characterized clinically or electrophy siologically.
CASE REPORT On January 4th, 1944, the patient, then a 21-yearold seaman, set sail from Staten Island, New York on a Navy escort ship bound for Guantanamo Bay, Cuba. Six hours out to sea his vessel, the U.S.S. Saint Augustine, was accidentally struck by a merchant marine ship. The Saint Augustine sank in 5 min, with loss of life to all but 29 of the 145 crew members. Immediately after being rescued, the sailor noticed the onset of an intermittent tremor that has persisted to this day and is reevoked by loud noise. He describes his ordeal in particularly tragic terms and he attributes his tremor to that ordeal. He changed his peace-time profession because of noise levels and is still vigilant to avoid loud
noises. When the patient has the tremor, he experiences a fear similar to that which he had when his ship sank. He has recurrent distressing dreams of the sinking of the ship, but these have decreased in recent years. He deliberately avoids any thought of the ship sinking, and ever since the sinking has been unable to watch a war movie or a mystery thriller without breaking out in a sweat. After the sinking of the ship, the patient became depressed and disinterested in his previous hobbies, such as fishing. He has been married and divorced three times. This patient meets the criteria for PTSD (Criteria A; B1, 2, 3, 4; C1, 2, 4; D4, 5 , 6; and E) (Table 1) (10). The patient drank heavily between 1955 and 1975, and then stopped. He is unsure whether alcohol abated the noise-induced tremor. In 1964, he contracted pneumonia while building highways in California. A diagnosis of San Jauquin Valley Fever was made, with subsequent left lower lobe pneumonectomy. The patient continued to be a four pack per day smoker and was later diagnosed with
TABLE 1. Diagnostic criteria for post-traumatic stress disorder ~
"A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone (e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence). B. The traumatic event is persistently reexperienced in at least one of the following ways: "1. Recurrent and intrusive distressing recollections of the event (In young children, repetitive play in which themes or aspects of the trauma are expressed) "2. Recurrent distressing dreams of the event "3. Sudden acting or feeling as if the traumatic event were recurring [includes a sense of reliving the experience, illusions, hallucinations, and dissociative (flashback) episodes, even those that occur upon awakening or when intoxicated] "4. Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma. C . Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: "1. Efforts to avoid thoughts or feelings associated with the trauma "2. Efforts to avoid activities or situations that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma (psychogenic amnesia) "4. Markedly diminished interest in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills) 5 . Feeling of detachment or estrangement from others 6. Restricted range of affect (e.g., unable to have loving feelings) 7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a long life). D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following: 1 . Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating "4. Hypervigilance " 5 . Exaggerated startle response "6. Physiologic reactivity on exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator). "E. Duration of the disturbance (symptoms in B, C, and D) of at least 1 month. Specify delayed onset if the onset of symptoms was at least 6 months after the trauma. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Copyright 1987, American Psychiatric Association. Criteria pertinent to patient. See text for details.
Movement Disorders, Val. 7, No. 4, 1992
NOISE-INDUCED PSYCHOGENIC TREMOR
335
FIG. 1. Patient’s handwriting before startle.
chronic obstructive pulmonary disease, for which he continues to take bronchodilators. At least 12 years after the sinking of the ship he noticed a continuous finer tremor. As far as he knows neither his parents nor any of his seven siblings ever had tremor. On examination the patient shows no signs of Parkinsonism. Prior to startle he displays a continuous smaller amplitude, and primarily postural/ kinetic tremor (see videotape). With very loud unexpected noises he has an exaggerated startle reaction (see videotape), followed by a much larger amplitude tremor that is prominent at rest, as well as during sustained posture and during action (see videotape). Although one loud noise can cause the larger amplitude, startle-induced tremor to last for several minutes, repeated loud noises over a few minutes can cause it to last for several days (see videotape) and then disappear (see videotape). Sometimes several days pass before a noise is loud and unexpected enough to again induce the larger amplitude tremor. Nonetheless, after the induction of this tremor, any unexpected noise, even a normal speaking voice from behind, may cause the patient to jump. Once evoked, the larger amplitude, noiseinduced tremor is continuous until it ceases. When asked to voluntarily suppress the tremor, the patient cannot do so (see videotape). However, when the patient is distracted, the larger amplitude, noiseinduced tremor temporarily disappears (see videotape). The patient’s handwriting is of moderate size
\
-
FIG. 2. Patient’s handwriting after startle.
FIG. 3. Circle drawn after startle.
and shows only minimal evidence of postural/ kinetic tremor at baseline (Fig. 1). After startle, the handwriting is much bigger and sometimes shows gross and sometimes minimal evidence of postural/ kinetic tremor (Fig. 2). After startle, a perfectly round circle has uniform waviness at the edges in the manner of the figures drawn by patients with psychogenic tremor, as depicted by Koller et al. (Fig. 3) (5). A CAT scan of the brain was negative in 1989. ELECTROPHYSIOLOGICAL METHODS Startle was studied through repetitive 105 dB 1 kHz tones with a 0.1 ms rise time and 10 ms plateau presented through headphones to both ears simultaneously. Recordings were made from the orbiculark oculi, mastoid, sternocleidomastoid, biceps, and anterior tibialis muscles. EEG and head movement were also monitored. One-second epochs were collected after each stimulus with a Pathfinder I1 (Nicolet, Madison, WI) clinical averaging system that sampled all channels once every millisecond. Stimuli were delivered in five blocks of four tones. The first block had an approximate inter-tone interval (ITI) of 5 min, while each successive block had a 1 min shorter IT1 (from second block, IT1 = 4 min to fifth block, IT1 = 1 min). Blocks were separated by a 5-min rest period. Records were reviewed offline, and latency and duration of electromyography
Movement Disorders, Vol. 7, No. 4, 1992
336
A . S. WALTERS AND W. A . HENING
(EMG) responses were determined with cursors. The EMG was full-wave rectified and integrated to obtain an integrated EMG (IEMG) value. EMG duration and IEMG were averaged by block. Habituation across blocks was scored as the percentage decrease in average EMG duration and IEMG compared to the average obtained for each subject in the first block. The patient was compared to a series of normal subjects (11,12). The patient's tremors were also studied during various activities with surface EMG of bilateral wrist flexors and extensors, and right arm biceps, triceps, and abductor pollicis brevis (APB). Accelerometry was performed on both hands. Records were sampled and inspected to determine tremor amplitude, frequency, and pattern. Tremor frequency was confirmed by spectral analysis of 2.56-s segments of EMG and accelerometry records.
RESULTS The patient shows a classical startle with rostrocaudal progression of involved muscles from the orbicularis oculi down the neuraxis to the limbs (See Fig. 4A to show involvement of the right arm). He showed great resistance to habituation of muscle responses (11,12). Latencies of muscle responses to loud clicks were otherwise within the normal range. Normal subjects showed decreases of >30% in EMG response duration and a 40% decrease in IEMG in the orbicularis oculi by the fourth block of stimuli (IT1 = 2 min). The patient showed no decrease in duration and
