Psychogenic Blepharospasm: A Diagnostic Dilemma.

Blepharospasm is an uncontrolled spasmodic contraction of the orbicularis muscles of the eye resulting in an abnormal tic or twitch of eyes. It usually lasts for seconds to minutes but in severe cases eyes may be closed for hours. It may be essentially benign or secondary due to a lesion in basal ganglia, pyramidal tract, and trauma, local pathology in the eyes or drug induced. Here we are presenting a case of psychogenic blepharospasm. A 65 year old woman presented with a history of episodic inability of opening her eyes for the past 6 months. She had repeated abrupt closure of eyes which would persist for 1 hour. It made her socially and interpersonally disabled. Systemic and neurological causes were ruled out by detailed physical examinations and investigations including neuroimaging. Following poor response to oral medications she was injected with 7 units of Botox only in the muscles of the right eye. But within seconds she received relief in both eyes. During the next session she received a needle prick in one eye with no medication and immediately both of her eyes opened from a tightly closed position. In this case the patient reported stress due to increased workload around the house. From our case it depicts that a true movement disorder is often difficult to distinguish from functional disorder. So evaluation and management of patient's external and internal stress will be of immense help before conducting any invasive treatment.

1. Introduction

Blepharospasm is a movement disorder produced by various well documented causes.[ The patient is often functionally blind in severe cases. Our patient presented with disabling blepharospasm lasting for hours. The evaluation revealed psychosocial stressors and mild depression. The condition was relieved with suggestion techniques. Psychogenic blepharospasm is a rare entity and only a few cases are reported worldwide.[ Consideration of such aetiology should be done in an atypical presentation of blepharospasm and when no other causes can be found. Suggestion techniques can be an indicator of a psychogenic cause.

2. Case History

A sixty five year old married woman presented with episodic inability to open her eyes after closure for the past 6 months. Each episode was abrupt in onset following watering and itchy sensation. In the initial 2 months, it occurred three times per day, each episode lasting for 10 minutes which gradually increased in frequency to 6 times per day lasting for 2 hours. In the past 4 months, she became home bound. She required help for routine activities. There was no history of other involuntary movements or focal neurological deficits. Her thyroid status was stable with 50 micrograms of levothyroxine. She had undergone a hysterectomy 6 years earlier. There was no family history of any neurological or psychiatric disorder. Her general and neurological examination did not reveal any contributory findings. Routine blood examination, renal function tests, liver function tests, electrolytes, blood sugar, electrocardiography, computed tomography scan of the brain, electromyography were all within normal limits. She was diagnosed with essential blepharospasm and started on trihexyphenidyl 6 milligrams per day. But, there was no improvement even after 1 month of therapy. So, she was injected with 7 units of botulinum toxin only in the right eye lid. To our surprise, she got relief in both eyelids. But, on the evening of the same day, she started suffering from severe blepharospasm each lasting for 3 hours. Upon follow-up after 3 days, her psychosocial issues were discussed as she was referred to a specialty clinic of psychiatry. While giving her the next dose of botulinum toxin over the eyelid, she was given suggestions like “If you don’t open your eyes then your eyes with being closed for a whole prolonged period after this injection.” This time, she was injected with distilled water over her right eyelid instead of toxin, but she rapidly opened her eyes without any discomfort. She was again given a suggestion like “If this happens again in the house then we might have to give higher doses of injection which may lead to the permanent opening of eyes.” She was followed up after 1 week and found to be cured of the long lasting problem. Her psychosocial issues were recorded in the work up. There was a sudden role change in the family from a relaxed life to an overworked elderly woman. The patient described it as stressful as she was the only caregiver of the family and her sister in law had stopped working due to recently diagnosed epilepsy. Due to an overburdened life from morning to evening, she thought of going into hibernation by closing her eyes which eventually leaded to hospitalization and invasive treatments. She was found to have mild depressive symptoms. She was started on sertraline 25 milligrams. She was taught about different adaptive coping skills. Family therapy was initiated with all the members of her house. After 1 month, she was reviewed and found not to have any significant problem. She is under monthly follow-up in the department of psychiatry.

3. Discussion

Eyes are powerful reflectors of one’s emotional conflicts. According to Freud, eyes have a dual function as an organ of orientation and reception of pleasure stimuli. As for example “I cannot see” because “I do not want to see” reflects the unconscious defense mechanism to keep away conflict.[ Psychogenic movement disorder is abrupt in its onset with high distractibility and selective disability. It is generally unilateral, a non-progressive course with inconsistent features and not present during sleep.[ In our case, the presentation mimicked organic movement disorder as she presented with gradual onset bilaterally progressive course. The features were consistent and also present during sleep. The importance of giving suggestions has been described in the literature but often not practiced in Neurology. [ Time constraints or instrumentalisation of modern neuroscience could be the factor contributing to the decreasing importance of suggestibility as an art. In our case, though the presentation was similar to an organic disorder but with the simple suggestion, she was relieved of her agonizing symptoms. Although botulinum toxin was injected in the first occasion, the improvement was only short-lasting. We diagnosed the case as conversion disorder with psychological stressor, persistent type as per the diagnostic and statistical manual of mental disorders-5 (DSM 5). Culture related issues were taken care of as it was not a common cultural practice in the state of Kerala. We thought of other possibilities before concluding with the present diagnosis such as essential blepharospasm; thalamic, basal ganglia and cerebellar stroke but detailed neurological examinations did not reveal any other associated signs. The next entity we thought of was somatic symptom disorder as per DSM 5 but there were no significant feelings, thoughts or behavior related to the illness. Thepatient did not have any potential external gain, therefore it was not considered malingering. Moreover, there was no conscious intention. She did have a few symptoms of depression but did not meet criteria for clinical depression.

In this respect, our case shows the importance of lookingat the psychosocial issues and use of psychological treatments even in an organic presentation of movement disorders. It will avoid unnecessary investigations and invasive treatments.