Treatment issues in psychogenic-neuropsychiatric movement disorders.

Patients with PNMDs pose a fascinating challenge to clinicians at the neurology-psychiatry interface. We have outlined a diagnostic and therapeutic approach to these complex disorders. Patients with PNMDs typically manifest abnormal movements and postures that do not fit expected patterns of movement disorder phenomenology. The first goal of neurologic consultation is to make an accurate diagnosis, with a view to either ruling out or defining the extent of any organic substrate. The next task is an effective referral to a psychiatrist capable of diagnosing relevant psychopathology and collaborating in a treatment plan. A supportive explanation of the diagnosis, one that is sensitive to the patient's intellectual capacity, conception of the illness, and self-esteem, appears to be a crucial determinant that influences the patient's capacity to be engaged effectively in treatment. The treatment for each patient with PNMD is individualized and may include psychotherapy, hypnosis, pharmacotherapy, physical therapy, and other approaches. To date, no treatment approach has been shown to be superior, and very few long-term outcome data are available. Although many factors influence response to treatment, those of particular importance are the effectiveness of communication among the neurologist, the psychiatrist, and the patient; the nature, severity, and chronicity of relevant psychopathology and environmental stressors; and the quality of external support and intrinsic resources available to the patient.