Psychogenic dystonia and peripheral trauma

Abstract

Dystonia in association with peripheral trauma is a well-described clinical syndrome. The syndrome goes by many names--"traumatic" dystonia, "fixed" dystonia, peripherally induced dystonia, or complex region pain syndrome (CRPS) dystonia. We reviewed the role of peripheral trauma in the development of dystonia, focusing on 4 subtypes--cervical dystonia, focal limb dystonia, CRPS dystonia, and psychogenic dystonia. We show that peripheral trauma inducing, provoking, or precipitating structural changes within the CNS leading to dystonia is not an accepted concept, and current evidence supporting a pathophysiologic mechanism is virtually nonexistent. A better approach to this clinical syndrome is to define it as fixed abnormal posturing that is most commonly psychogenic. While symptomatic treatment of pain and spasms with medication can be beneficial, early psychological evaluation and patient-specific treatment is important. Modalities such as physical and occupational therapy should be utilized early. Finally, it should be emphasized that like many psychogenic movement disorders, it remains a highly disabling and distressing disorder.

Sensory aspects of movement disorders

“…Because only a small group of patients develop dystonia in the setting of CRPS, some genetic predisposition might exist in patients who do develop this form of peripherally induced dystonia. 140 The presence of affective disorders and of psychogenic features in these patients has led some researchers to propose that dystonia in the setting of peripheral injury is largely of psychogenic origin 137,143 or a form of body integrity identity disorder. 144 More data are needed to better understand the CRPS dystonia syndrome.…”

Functional (psychogenic) movement disorders

“…In a recent review of the literature on 713 patients with peripherally induced movement disorders [40], the authors find overlap with FMD in 15% of cases, but argue for presence of an organic movement disorder triggered by peripheral trauma in the majority of cases. An opposing view is taken by Hawley and Weiner [41], who make a case for a predominant psychogenic etiology in patients peripheral trauma associated dystonia. The use of electrophysiological methods such as measurements of cortical plasticity in this patient population [42] will hopefully provide a more definitive answer on the underlying pathophysiology in these cases.…”

Traumatic Dystonia

“…Physiological mechanisms for traumatic dystonia have been suggested alongside psychogenic causes, but none has proven conclusive. 3,9 The vast majority of those subjected to local injury do not develop dystonia, so the trauma is not the sole cause, but it seems more probable that is the trigger to the appearance of dystonia in those predisposed to develop this illness. The hypothesis that peripheral injury might precipitate dystonia in those carrying the idiopathic torsion dystonia gene or genes is consistent with the findings of familial cases among patients with trauma induced dystonia.…”

“…Similarly, if as studies have shown there is a strong link between traumatic dystonia and psychogenic movement disorders, the psychological factors associated should be addressed as a matter of urgency. 3,10 Botulinum toxin A takes 2 days to commence working with its peak efficacy occurring in the second week. An instant effect following injection, as in this case, is therefore supportive of a functional component to the disorder.…”

“…2,3,10 Timely referral to neurologists within a multidisciplinary team for assessment, investigation, and treatment can improve the outcome from this disabling syndrome. 3 This case report documents a patient who developed a fixed dystonia following trauma to her lower leg who presented to an orthopaedic outpatient fracture clinic. It serves to highlight the nature of the condition, difficulties in investigating the disorder, and management of the condition.…”