Psychogenic Contractures: The Magic Side of Medicine

Sir,

Psychogenic movement disorders are a well-known phenomenon in neurological departments and may be responsible for up to 2 - 3 % of unexplained neurological symptoms [[1]]. Only rarely are these movement disorders of such extent that they result in joint contractures. During World War I, however, Stern was able to publish 230 cases of psychogenic movement disorders leading to contractures and referred to them as “a mass phenomenon during war” [[3]]. Since then psychogenic contractures have become a rare topic in the medical literature. The most recent report we are aware of is the Polish article by Zwierzchowski et al (1989) describing three cases of psychogenic contractures among young girls [[6]]. By reporting a further case we would like to draw attention to this poorly understood condition.

A 14-year-old girl was referred to our hospital because of a “movement disorder” that had started 18 months previously. She claimed that “suddenly” muscle strength in her right foot had begun to weaken and subsequently she had become unable to flex her right ankle which led to constant right-sided toe-walking. Despite physiotherapy the condition slowly deteriorated and finally resulted in a monoplegic gait with flexion contractures of the right knee and ankle. An arthroscopy of the right knee, measurements of the peripheral nerve conduction velocity, as well as an MRI scan of the brain were performed but the reason for the girl's progressive gait disturbance could not be determined. Astonishingly the girl did not consider herself as being handicapped although the contractures prevented free motion of the right leg; she attended school as usual and even continued to go dancing. However, in the long run an operative lengthening of the tendo-Achilles became inevitable. Preoperatively, the girl was referred to us for a new diagnostic approach.

The internal examination of the girl was entirely normal. There was right-sided toe-walking due to a tendo-Achilles contracture with almost impossible dorsiflexion of the right foot. The right leg was held slightly bent at the hip and knee to compensate for the different leg length caused by the one-sided toe-walking. This had resulted in an incomplete contracture of the right knee. The entire right leg showed a marked muscular hypotrophy. Deep tendon reflexes were normal, there were no signs of spasticity and no loss of sensory function. Since an abnormality of the brain had already been excluded, we performed an MRI scan of the pelvis which did not reveal anything suspicious. Similarly, somatosensory evoked potentials of the tibial nerves were normal and thus did not suggest a lesion of the spinal roots. Neither motor nor sensory nerve conduction studies of the lower extremities showed any abnormalities, excluding a peripheral neuropathy. Electromyography of the right gastrocnemius muscle revealed normal muscle potentials, silent muscle activity at rest, a normal recruitment of motor units during increasing effort and a “full” interference pattern at maximal voluntary force. There were no myopathic or neurogenic changes of muscle potentials and no involuntary muscle activity so that no evidence for a myopathy, a spinal muscular atrophy or a dystonic movement disorder was found. Despite the rather young age of our patient we also considered a benign monomelic amyotrophy of the lower limb (BMALL) as underlying disorder. However, although marked unilateral amyotrophy of the lower limb was present, electromyography did not show neurogenic changes which was a consistent finding in almost all previously reported patients [[2]].

In this situation the girl's mother asked if the condition might have a psychogenic origin. A detailed psychological exploration revealed that the girl's father had died several years ago from a lung carcinoma. This loss was partially compensated by the girl's grandfather who lived in the same household and to whom she had developed a very close relationship. Shortly after the father's death the grandfather was diagnosed with a malignant disease in the course of which he developed a movement disorder and became wheelchair-bound. This wheelchair had been constructed by the grandfather himself and was - in the girl's words - “very cool”. Years after the grandfather had died from his disease the widowed mother found a new partner who finally moved into the family's house. This resulted in numerous conflicts between family members and coincided with the girl's movement disorder which started when a heavy metal plate fell on her right foot. Although this initial trauma did not lead to any organic damage it was followed by recurrent episodes of disturbed gait which appeared to become the more severe the closer the mother's relationship to her new partner was. Finally, the mother's partner moved out again which improved the conflict-ridden family situation but did not change the girl's movement disorder.

This personal history and the absence of any organic disease suggested a psychogenic disorder with the described tendon contractures and muscular hypotrophy being secondary phenomena due to impaired movement. Several diagnostic criteria for a psychogenic condition were fulfilled [[1], [5]]:

the onset of symptoms was obviously connected to a time of heavy personal conflicts, the type of symptoms could easily be explained by the girl's close relationship to her grandfather and his type of movement disorder, the restricted movement was not considered a physical handicap or a “burden” by the affected girl - a phenomenon known as “belle indifférence” in psychoanalysis, the girl's behavior revealed an almost affectionate relationship towards “her” symptom.

Following current classification systems for psychiatric disorders we could therefore establish the diagnosis of a somatoform disorder (DSM-IV: 300.81) or a dissociative disorder of movement and sensation (ICD-10: F45.0). The presumed underlying conflicts were addressed in several therapeutic sessions and an operative tendo-Achilles lengthening was performed. Together with physiotherapy and night splinting this resulted in a fully restored mobility of the right leg which was still preserved one year after the operation. No further neurological symptoms were observed in the girl.

In summary, this case demonstrates that even in the presence of an obvious organic malfunction such as a joint contracture the search for an underlying disorder might be frustrating when only widely-held assumptions of how diseases develop are considered. Adding psychopathological processes as possible disease mechanisms opens up a new field of investigation - but does not necessarily enhance our understanding of what is really going on. For the interpretation of the presented case we would like to refer to David Taylor who regarded these somatic disease manifestations as “a defence mechanism…which from one perspective we call hysteria, but from another perspective we understand as belief, and from another as magic” [[4]].

References

• 1 Feinstein A, Stergiopoulos V, Fine J, Lang A E. Psychiatric outcome in patients with a psychogenic movement disorder.  Neuropsychiatry Neuropsychol Behav Neurol. 2001;  14 169-176
• 2 Münchau A, Rosenkranz T. Benign monomelic amyotrophy of the lower limb - case report and brief review of the literature.  Eur Neurol. 2000;  43 238-240
• 3 Stern H. Die hysterischen Bewegungsstörungen als Massenerscheinung im Krieg ihre Entstehung und Prognose. Dissertation. Heidelberg; 1917
• 4 Taylor D C. Hysteria, belief, and magic.  Br J Psychiatry. 1989;  155 391-398
• 5 Williams D T, Ford B, Fahn S. Phenomenology and psychopathology related to psychogenic movement disorders. Weiner WJ, Lang AE Behavioral Neurology of Movement Disorders. New York; Raven Press 1995: 231-257
• 6 Zwierzchowski H, Zwierzchowska D. Psychogenne przykurcze stawów.  Chir Narz Ruchu Ortop Pol. 1989;  1 63-66