Descriptive Psychopathology: The Signs and Symptoms of ...

183 Chapter 7: Disturbances of motor functionShe looked tense, with clenched teeth and tension in her general musculature.She had several episodes daily, lasting several minutes, and these werefollowed by the desire to lie down and sleep. On one occasion she wasincontinent of urine. Although “conversion hysteria” was diagnosed by theattending psychiatrist, the resident considered seizure disorder likely,obtained a prolactin blood level 20min after such an episode which wasfour times the patient’s baseline and diagnostic of a seizure. Anticonvulsanttreatment resolved the episodes. 124The tell-tale signs of pseudo- or non-epileptic seizure are well known. All,however, are also expressions of true seizures. 125In an extensive review, Krem (2004) details many severe neurologic conditionspresenting with features initially eliciting the diagnosis of conversion disorder.More than 60% of such patients were young women. Common psychiatricco-morbidities were depression and personality disorder. Among the identifiedcauses of motor conversion were amyotrophic lateral sclerosis, Guillain–Barrésyndrome, Huntington’s disease, intracranial hemorrhage, malignancy, multiplesclerosis, myasthenia gravis, Parkinson’s disease, post-encephalitis syndrome, andsystemic lupus erythematosis.Mood disorder is another common co-morbidity among patients defined witha psychogenic movement disorder. 126 Further, just as epilepsy is a commonfinding in patients who also have non-epileptic seizures, 127 many patients withthe diagnosis of psychogenic movement disorder also have a movement disordersecondary to a neuropathologic process. 128Diagnostic and treatment considerations alone indicate that if a defined illnessexplaining the movement disorder cannot be determined it is best to considersuch patients as having idiopathic movement disorders, not “psychogenic” or“conversion” disorder.Psychogenic movement disorder, however, is typically diagnosed when othercauses are not apparent, the movements are inconsistent with the clinician’sunderstanding of neurologic functioning and disease, and the movements tend toworsen when the patient is under stress and improve with distraction or placebo.Idiopathic movement disorder is also commonly associated with sensory symptomsor pain. La belle indifference is not a consistent or specific finding. Thalamiclesions, however, can elicit motor disturbance, sensory symptoms and neglect or“denial” of dysfunction, and such lesions are not always considered in the evaluationof patients with idiopathic movement disorder. 129 Female patients are morelikely than men to receive the diagnosis. Most patients remain symptomatic foryears, and few consider their condition as primarily psychiatric in origin, despitemany having a psychiatric co-occurring condition. 130