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

Psychogenic dystonia is one of the most common problems encountered in movement disorder patients and accounted mostly for misdiagnosis, management confusion and treatment resistance. Psychiatric morbidities often are the culprit, hence proper psychiatric history taking is of utmost importance. Here we report one case where dystonia was the main presenting complaint of an underlying depressive episode and discuss how managing the cause alleviated the symptoms.

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.[ 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. [ Although primarily regarded solely as psychogenic, from the 1970s onwards the organic theories prevailed, the strongest of which is about the DYT1 gene. [ But psychogenic dystonia is a specific entity among the realm of FMD, which occurs in around 10-20% of cases, according to the criteria.[ 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.[ 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).[ 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.[ Our case highlights that closely watching clinical manifestations, in-depth psychiatric screening, and improved multidisciplinary management are necessary for all cases of psychogenic dystonia.