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
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P U B L I S H E D
A R T I C L E S
volume, the editors noted: “A problem with the term ‘functional’ is that it might imply normal function rather than dysfunction and contradicts the notion that the treating physician wants and should convey to the patient about the ‘cause’ of the psychogenic disorder.” These are some of the reasons why I still prefer the term psychogenic instead of functional. Patients who present with these disorders generally perceive themselves as “dysfunctional” rather than “functional.” Furthermore, I believe that the latter term is too vague. When the term psychogenic is introduced to the patients in a sensitive and tactful way and the patients are reassured that there is no evidence of “neurological damage,” they are more willing to accept the role of psychodynamic factors, such as stress, in their condition and are more amenable to psychological and psychiatric intervention. Most patients understand that stress can cause elevation in blood pressure, palpitation, and tremors, so they can also accept that dystonia, parkinsonism,5 tics,6 and other movement disorders can be manifestations of stress or other psychological factors, even though these precipitants may not always be obvious or readily identifiable, especially during the first encounter. Joseph Jankovic, MD Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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.
Hallett M, Fahn S, Jankovic J, Lang AE, Cloninger CR, Yudofsky S, eds. Psychogenic Movement Disorders: Neurology and Neuropsychiatry. Philadelphia, PA: AAN Enterprises and Lippincott Williams and Wilkins, 2006:1-353.
4.
Hallett M, Cloninger CR, Fahn S, Halligan P, Jankovic J, Lang AE, Voon V. Psychogenic Movement Disorders and Other Conversion Disorders. Cambridge, UK: Cambridge University Press, 2011: 1-324.
5.
Jankovic J. Diagnosis and treatment of psychogenic parkinsonism. J Neurol Neurosurg Psychiatry 2011;82:1300-1303.
6.
Baizabal-Carvallo JF, Jankovic J. The clinical features of psychogenic movement disorders resembling tics. J Neurol Neurosurg Psychiatry 2014;85:573-575.
-----------------------------------------------------------*Correspondence to: Joseph Jankovic, MD, Professor of Neurology, Distinguished Chair in Movement Disorders, Director of Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030, 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: 29 June 2014; Accepted: 24 August 2014 Published online 24 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.26040
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Functional or Psychogenic: What’s the Better Name? We are pleased to see that functional/psychogenic movement disorders are gaining broader recognition within the movement disorders field, because they are very common issues in daily practice. We have welcomed the recent change in the naming convention from “psychogenic” toward “functional” by many authors in the field (as well as DSMV) and fully agree with the arguments brought forward by Edwards, Stone, and Lang in their proposal.1 That not all patients have psychopathology or a history of a traumatic event that appears to be related to their movement disorder is well recognized,2 and this is acknowledged by Drs. Fahn and Olanow in their commentary.3 As stated, a psychological factor does not need to be present to make the diagnosis. Drs. Fahn and Olanow, however, strongly argue in favor of the use of “psychogenic,” therefore trying to reestablish the mind/body dualism that the term “functional” seeks to avoid. Psychological causes certainly play a role in pathogenesis in many cases, but the etiology is more complex than the mentioned example of posttraumatic stress syndrome, which by definition requires a preceding traumatic event. Recent neuroimaging studies have begun to shed a light on a deeper understanding of these conditions, and using a neutral term such as “functional” appears preferable to encourage further research efforts. Drs. Fahn and Olanow furthermore argue that the term “psychogenic” is well accepted as long as the diagnosis is conveyed “tactfully” to the patient. The word “tact/ tactfully” is in fact used five times in their article, which makes one wonder why it should be necessary to use more tact when giving this particular diagnosis than any other diagnosis with uncertain etiology. A commonly used approach is suggested of telling the patients first what they don’t have, and after a lengthy discussion mentioning the term “psychogenic” almost as an afterthought. As recently suggested by Stone et al.,4 it appears to be more appropriate to start the conversation by naming the condition (“you have a functional movement disorder”), subsequently explaining how the diagnosis was reached and laying out treatment plans, just as we do for other complex disorders such as multiple sclerosis. A major problem in treating patients is the first step, their acceptance of the diagnosis. Many patients are unwilling to accept “psychogenic,” and the patient moves on to the next neurologist. “Functional” is better accepted, and, of course, possible psychological aspects of the etiology can certainly be introduced as appropriate as part of the discussion with the patient.
------------------------------------------------------------
*Correspondence to: Dr. Kathrin LaFaver, Department of Neurology, Movement Disorder Division, University of Louisville Physicians, 220 Abraham Flexner Way, Suite 606, Louisville, KY 40202, E-mail: [email protected] Funding agencies: none
Relevant conflicts of interest/financial disclosures: Nothing to report. Author roles may be found in the online version of this article. Received: 25 May 2014; Revised: 10 June 2014; Accepted: 24 August 2014 Published online 21 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.26035
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
1697
L E T T E R S :
P U B L I S H E D
A R T I C L E S
volume, the editors noted: “A problem with the term ‘functional’ is that it might imply normal function rather than dysfunction and contradicts the notion that the treating physician wants and should convey to the patient about the ‘cause’ of the psychogenic disorder.” These are some of the reasons why I still prefer the term psychogenic instead of functional. Patients who present with these disorders generally perceive themselves as “dysfunctional” rather than “functional.” Furthermore, I believe that the latter term is too vague. When the term psychogenic is introduced to the patients in a sensitive and tactful way and the patients are reassured that there is no evidence of “neurological damage,” they are more willing to accept the role of psychodynamic factors, such as stress, in their condition and are more amenable to psychological and psychiatric intervention. Most patients understand that stress can cause elevation in blood pressure, palpitation, and tremors, so they can also accept that dystonia, parkinsonism,5 tics,6 and other movement disorders can be manifestations of stress or other psychological factors, even though these precipitants may not always be obvious or readily identifiable, especially during the first encounter. Joseph Jankovic, MD Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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.
Hallett M, Fahn S, Jankovic J, Lang AE, Cloninger CR, Yudofsky S, eds. Psychogenic Movement Disorders: Neurology and Neuropsychiatry. Philadelphia, PA: AAN Enterprises and Lippincott Williams and Wilkins, 2006:1-353.
4.
Hallett M, Cloninger CR, Fahn S, Halligan P, Jankovic J, Lang AE, Voon V. Psychogenic Movement Disorders and Other Conversion Disorders. Cambridge, UK: Cambridge University Press, 2011: 1-324.
5.
Jankovic J. Diagnosis and treatment of psychogenic parkinsonism. J Neurol Neurosurg Psychiatry 2011;82:1300-1303.
6.
Baizabal-Carvallo JF, Jankovic J. The clinical features of psychogenic movement disorders resembling tics. J Neurol Neurosurg Psychiatry 2014;85:573-575.
-----------------------------------------------------------*Correspondence to: Joseph Jankovic, MD, Professor of Neurology, Distinguished Chair in Movement Disorders, Director of Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030, 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: 29 June 2014; Accepted: 24 August 2014 Published online 24 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.26040
1698
Movement Disorders, Vol. 29, No. 13, 2014
Functional or Psychogenic: What’s the Better Name? We are pleased to see that functional/psychogenic movement disorders are gaining broader recognition within the movement disorders field, because they are very common issues in daily practice. We have welcomed the recent change in the naming convention from “psychogenic” toward “functional” by many authors in the field (as well as DSMV) and fully agree with the arguments brought forward by Edwards, Stone, and Lang in their proposal.1 That not all patients have psychopathology or a history of a traumatic event that appears to be related to their movement disorder is well recognized,2 and this is acknowledged by Drs. Fahn and Olanow in their commentary.3 As stated, a psychological factor does not need to be present to make the diagnosis. Drs. Fahn and Olanow, however, strongly argue in favor of the use of “psychogenic,” therefore trying to reestablish the mind/body dualism that the term “functional” seeks to avoid. Psychological causes certainly play a role in pathogenesis in many cases, but the etiology is more complex than the mentioned example of posttraumatic stress syndrome, which by definition requires a preceding traumatic event. Recent neuroimaging studies have begun to shed a light on a deeper understanding of these conditions, and using a neutral term such as “functional” appears preferable to encourage further research efforts. Drs. Fahn and Olanow furthermore argue that the term “psychogenic” is well accepted as long as the diagnosis is conveyed “tactfully” to the patient. The word “tact/ tactfully” is in fact used five times in their article, which makes one wonder why it should be necessary to use more tact when giving this particular diagnosis than any other diagnosis with uncertain etiology. A commonly used approach is suggested of telling the patients first what they don’t have, and after a lengthy discussion mentioning the term “psychogenic” almost as an afterthought. As recently suggested by Stone et al.,4 it appears to be more appropriate to start the conversation by naming the condition (“you have a functional movement disorder”), subsequently explaining how the diagnosis was reached and laying out treatment plans, just as we do for other complex disorders such as multiple sclerosis. A major problem in treating patients is the first step, their acceptance of the diagnosis. Many patients are unwilling to accept “psychogenic,” and the patient moves on to the next neurologist. “Functional” is better accepted, and, of course, possible psychological aspects of the etiology can certainly be introduced as appropriate as part of the discussion with the patient.
------------------------------------------------------------
*Correspondence to: Dr. Kathrin LaFaver, Department of Neurology, Movement Disorder Division, University of Louisville Physicians, 220 Abraham Flexner Way, Suite 606, Louisville, KY 40202, E-mail: [email protected] Funding agencies: none
Relevant conflicts of interest/financial disclosures: Nothing to report. Author roles may be found in the online version of this article. Received: 25 May 2014; Revised: 10 June 2014; Accepted: 24 August 2014 Published online 21 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mds.26035
