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Functional movement disorders

Author
Janis M Miyasaki, MD, MEd
Section Editor
Howard I Hurtig, MD
Deputy Editor
John F Dashe, MD, PhD

INTRODUCTION AND BACKGROUND

Functional movement disorders (FMDs) are clinical syndromes defined by the occurrence of abnormal involuntary movements that are incongruent with a known neurologic cause and are significantly improved on neurological exam with distraction or nonphysiologic maneuvers [1]. This definition replaces the previous one that considered FMDs to be "psychogenic movement disorders" and attributed the occurrence of the abnormal movements to a psychiatric cause [2]. FMDs were first described in the late 19th and early 20th centuries and have been the subject of great interest and puzzlement ever since [3-5]. In addition to "psychogenic," alternative terms for FMDs include "hysterical" or "nonorganic" movement disorders and "medically unexplained" motor symptoms [6]. In modern times, awareness of FMDs has increased in the movement disorder literature. However, the pathogenesis and pathophysiology of FMDs are not fully understood [1,7-9], and debate continues as to whether "functional" or "psychogenic" is the better term for these movement disorders [10-16].

The dangers of FMDs are manifold: excessive and unnecessarily costly investigation of FMD resulting in reinforcing the sick role, misdiagnosing organic illness as psychogenic [17], misdiagnosing FMD as organic, and failure to recognize a kernel of organic illness embedded in the symptoms of a FMD [18]. The prevalence, poor prognosis, and intensive healthcare utilization of FMDs present a problem that has been likened to a crisis in neurology [19]. In order to offer the best chance for remission and to use scarce resources wisely, rapid and accurate diagnosis of FMDs is essential.

This topic will review clinical aspects of FMDs, including epidemiology, clinical features, diagnosis, management, and prognosis.

EPIDEMIOLOGY

The precise incidence and prevalence of FMDs are unknown, as population-based studies are unavailable. Estimates of the prevalence of FMD among adults and children with movement disorders vary between 2 to 4 percent [20-25]. Women are affected more often than men. A retrospective chart review of our center in Toronto yielded 206 patients with a diagnosis of FMD out of 7624 records, for a prevalence of 3 percent [20]. Of note, our center receives referral from both primary care physicians and from other academic movement disorders centers. The prevalence of FMD among patients who present with dystonia and fixed, contracted joints may be even higher. As an example, one study of 41 such patients with prospective data reported that criteria for functional dystonia were fulfilled in 15 (37 percent) [26].

In most reports of adults and children with FMD, functional tremor is the most frequent type of involuntary movement, followed by functional dystonia [20,27-29]. Among our cohort of 206 patients with FMD, the most common functional involuntary movements were tremor (33 percent), dystonia (25 percent), myoclonus (25 percent), gait disorders (11 percent), and parkinsonism (6 percent) [20]. Women comprised 77 percent of the total cohort. Although our population is culturally diverse, a formal study of transcultural differences that compared patients with FMD from the United States and Spain revealed similar frequencies of movement types, gender, anatomic distribution, and disability across ethnic groups [30].

                        

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Literature review current through: Feb 2015. | This topic last updated: Feb 26, 2015.
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