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"The Twisted Mind" - Psychogenic Dystonia in An Adolescent, Responding to Antidepressant Therapy.

1. Introduction

Dystonia is rarely psychogenic, but this etiology is suggested when clinical characteristics are inconsistent and incongruous with a classical disorder. Within the realm of functional (psychogenic) movement disorder (FMD), functional dystonia is one of the most common.[1] Being in an interdisciplinary area and having the requirement of detailed examination, which is not in the standard armamentarium of either neurologist and psychiatrists, misdiagnosis and treatment failure is a common phenomenon; hence this report.

2. Case report

A thirteen year old male presented with progressively increasing spasm and rigidity on the right side of his body especially the neck, upper torso and leg for the past 6 months. It started while walking and steadily increased in frequency and severity. For the previous one month, the episodes of exacerbation happened two to three times per day, stayed around thirty minutes and then resolved gradually. Breathlessness and palpitation preceded the attacks, though he never lost consciousness.

Patient was admitted to neurology where all routine imaging including EEG and EMG were performed and having come back normal, he was recommended for detailed neurological examination. Seven days of treatment with a muscle relaxant and anticholinergics did not show any improvement. Afterwards, observing the suggestibility, that it was precipitated with stress, having nil investigation findings, ameliorating with sensory tricks, the patient was referred to psychiatry, where after a detailed clarification of history, he was diagnosed with 'Severe Depression without psychotic symptoms'. Hamilton depression scale (HAMD) score was 24, indicating very severe depression. Rorschach and Thematic Apperception Test revealed significant interpersonal conflicts and internal stress. We started the patient on Escitalopram 10 mg and Clonazepam 0.25mg with intense, structured psychotherapy and family intervention. In the following 2 weeks the patient's condition notably improved. For the next two months he received follow up with no recurrences.

3. Discussion

From first being described in 1911 as "sustained muscle contractions", dystonia has travelled a long way. [2] Although primarily regarded solely as psychogenic, from the 1970s onwards the organic theories prevailed, the strongest of which is about the DYT1 gene. [3,4] But psychogenic dystonia is a specific entity among the realm of FMD, which occurs in around 10-20% of cases, according to the criteria.[5] FMD is characteristically abrupt in onset with high distractibility, selective disability, generally unilateral, a non-progressive course with inconsistent features and does not occur during sleep.[5,6] Our case matches the general characteristics of the above mentioned description. Also, the patient improved with psychotropics and psychotherapy which also indicates a diagnosis of functional dystonia.

Among the patients diagnosed as having dystonia, the prevalence of psychogenic cause may range from 2.2% to 4.6% depending on the criteria used (documented, clinically definite, probable or possible psychogenic dystonia).[8] Psychiatric co-morbidities like depression (20%), anxiety disorders (38%) [social phobia, agoraphobia, panic disorder] and personality disorders (45%) are present to a significant extent, and are of great prognostic importance.[9,10] Our case highlights that closely watching clinical manifestations, in-depth psychiatric screening, and improved multidisciplinary management are necessary for all cases of psychogenic dystonia.

Funding statement

No funding was obtained for this report.

Conflicts of interest statement

The authors declare no conflict of interest related to this manuscript.

Patient's informed consent

The patient signed informed consent for the present report's publication.

Authors' contributions

SSC: Case management, literature search, writing manuscript, editing

SD: Writing manuscript

SG: Editing

SB: Editing

[phrase omitted]

Chatterjee SS, Das S, Gupta S, Bhattacharya S

[phrase omitted]

References

[1.] Peckham EL, Hallett M. Psychogenic Movement Disorders. Neurologic Clinics. 2009; 27(3): 801-vii. doi: http://dx.doi.org/10.1212/01.CON.0000436160.41071.79

[2.] Oppenheim HU". [ber eine eigenartige Krampfkrankheit des kindlichen und jugendlichen Alters (Dysbasia lordotica progressiva, Dystonia musculorum deformans)]. Neurologisches Centralblatt. 1911; 30:1090-107. German

[3.] Ozelius U, Hewett JW, Page CE, Bressman SB, Kramer PL, Shalish C, et al. The early-onset torsion dystonia gene (DYT1) encodes an ATP-binding protein. Nature genetics. 1997; 17(1): 40-48. doi: http://dx.doi.org/10.1038/ng0997-40

[4.] Eidelberg D, Moeller JR, Antonini A, Kazumata K, Nakamura T, Dhawan V, et al. Functional brain networks in DYT1 dystonia. Ann Neurol. 1998; 44(3): 303-312.

[5.] Williams DT, Ford B, Fahn S. Phenomenology and psychopathology related to psychogenic movement disorders. Adv Neurol. 1995; 65: 231-257

[6.] Lang AE. Psychogenic dystonia: a review of 18 cases. Can J Neurol Sci. 1995; 22(2): 136-143

[7.] Das S, Sreedharan RP, Remadevi PS, Saji CV. Psychogenic blepharospasm : a diagnostic dilemma. Shanghai Arch Psychiatry. 2016; 28(6): 346-348. doi: http://dx.doi.org/10.11919/j.issn.1002-0829.216056

[8.] Fahn S, Williams DT. Psychogenic dystonia. Adv Neurol. 1988; 50: 431-455.

[9.] Feinstein A, Stergiopoulos V, Fine J, Lang AE. Psychiatric outcome in patients with a psychogenicmovement disorder: a prospective study. Neuropsychiatry Neuropsychol Behav Neurol. 2001; 14(3): 169-176

[10.] Factor SA, Podskalny GD, Molho ES. Psychogenic movement disorders: frequency, clinical profile, and characteristics. J Neurol Neurosurg Psychiatry. 1995; 59(4): 406-412

Seshadri Sekhar CHATTERJEE, (1*) Soumitra DAS, (2) Sukanya GUPTA, (3) Sanhita BHATTACHARYA (4)

(1) Medical College, Kolkata, West Bengal, India

(2) NIMHANS, Bangalore, India

(3) West Bengal Health Service, India

(5) Derbyshire NHS, United Kingdom

(*) correspondence: Seshadri Sekhar Chatterjee; Mailing address: Medical College, Kolkata; 88 College Street, Kolkata, India; Postcode: 700073; E-Mail: drsschatterjee@gmail.com

Seshadri Sekhar Chatterjee obtained an MD degree from the Institute of Psychiatry, Kolkata, West Bengal, India, and post doctoral fellowhip from NIMHANS, Bengaluru,lndia. Now he is working as an attending doctor cum clinical tutor in the department of psychiatry of the Kolkata Medical College, West Bengal, India. His research interests include organic psychiatry and geriatric psychiatry.

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Article Details
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Title Annotation:CASE REPORT
Author:Chatterjee, Seshadri Sekhar; Das, Soumitra; Gupta, Sukanya; Bhattacharya, Sanhita
Publication:Shanghai Archives of Psychiatry
Article Type:Case study
Geographic Code:9INDI
Date:Apr 1, 2018
Words:949
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