Psychogenic Disorders

Some of the most challenging patients seen by neurologists don't have neurological disorders. These patients have neurological symptoms and often have abnormal findings on examination. However, they arise from underlying psychiatric distress or illness, rather than brain dysfunction as traditionally conceived by neurologists. This issue of Seminars in Neurology is entitled “Psychogenic Disorders,” but could equally be called “Nonorganic Disorders,” “Functional Disorders,” “Somatoform Disorders,” or “Hysteria.” Even though there is not likely to be agreement among those of us who care for such patients about the proper nomenclature, we can all agree that patients with psychogenic disorders are tough.

The initial hurdle is to make the diagnosis of a psychogenic disorder and this often tests one's diagnostic skills. In the background, we are haunted by the fear of missing something “real.” Thoroughness, judicious use of testing, liberal consultations with specialists, and long-term follow up are the best defenses. Yet, failure to recognize a psychogenic disorder has serious consequences as well: patients are subjected to unnecessary tests and therapies, all the while not being directed toward appropriate intervention. As these chapters demonstrate, psychogenic disorders are diagnosed not only by ruling-out an organic cause, but also by demonstrating positive findings from the history and examination that are incompatible with a neurological disorder, sometimes corroborated by laboratory tests.

Many times, uncovering the fuel that's firing a psychogenic disorder comes from the history, and it becomes necessary to delve into areas that as neurologists we often don't devote enough attention to: past or ongoing emotional, physical, or sexual abuse; personality disorders or vulnerabilities; depression; anxiety; sources of stress; substance abuse; and interpersonal relationships. The motivations for abnormal illness behavior are diverse ranging from simple attention, to compensation, to escape from responsibility, and in some cases, the “cause” cannot be discerned.

As tough as it can be to diagnose a psychogenic disorder, managing the patient is an equal if not greater challenge. When I show videotapes of patients with psychogenic movement disorders, the most frequent question I'm asked is: “What did you tell the patient was wrong?” This depends. I try to make an assessment of what the patient is prepared to hear. For some, especially if the disorder is short-lived, simply reassurance that their symptoms don't reflect something ominous or permanent may be enough. For others, I discuss the influence of the mind on the body emphasizing that their disorder is involuntary (assuming it is not malingering). Others are told they have an involuntary psychogenic movement disorder; in some cases, I emphasize that the primary problem is stress or depression. Some of these discussions are well received and patients get better; others go over like a lead balloon and I never see the patient again. Ideally, all such patients should be cared for with the help of a psychiatrist, but some finesse is often required as many patients are resistant.

No progress can be made for the patient with a psychogenic illness unless there is a trusting physician-patient relationship. This is aided by recognizing that the overwhelming majority of such patients are in fact ill: they are legitimately distressed and suffering. The first article in this issue of Seminars, by psychiatrist Karen Anderson, puts psychogenic illness into the proper semiologic perspective. Dr. Anderson has earned her stripes by seeing virtually all of the patients with psychogenic movement disorders encountered at the University of Maryland Parkinson's Disease and Movement Disorders Center. My article follows, focusing on the features that distinguish psychogenic movement disorders. Contrasting with the positive clinical manifestations of psychogenic movement disorders-including tremor, myoclonus, and dystonia-are the negative disorders of weakness and sensory loss. Next, Dr. Doug Lanska, a neurological polymath who has written on virtually everything, both modern and historical, provides an excellent perspective on diagnosing functional weakness and sensory loss.

We are all taught Hoover's sign of psychogenic weakness and the touch/no-touch test for psychogenic anesthesia. There is similar battery of bedside tests to distinguish organic from nonorganic visual loss, as discussed authoritatively by Dr. Neil Miller. In addition to impaired sensation and vision, hearing may also be reported as lost or diminished on a psychogenic basis. Documenting that hearing is present when none seems apparent requires the assistance of an otolaryngologist and audiologist. Much more technical than detecting nonorganic movement disorders, weakness, or numbness, Drs. James Lin and Hinrich Staecker take us through an evaluation of the patient with suspected psychogenic deafness.

Some patients with psychogenic disorders hear well, see and move normally, but don't remember their name, where they were born, or recognize family members. The movies and television would have us believe that this is amnesia from brain damage. But is it? The answer is in the next chapter on psychogenic amnesia by neuropsychologists Drs. Jason Brandt and Wilfred G. Van Gorp. Next, epileptologists Drs. Allan Krumholz and Jennifer Hopp discuss psychogenic seizures, or as they are often called: “nonepileptic seizures.” Although I have never liked that label (would you consider a “nonmovement disorder movement disorder”?), it detracts not a bit from their authoritative discussion based on extensive experience in the trenches (aka Epilepsy Monitoring Unit) with such challenging patients. Next-to-last, Dr. Lewis Sudarsky, who traditionally investigates neurological causes of gait disorders, writes instead on gait disorders that look neurological but aren't. After reading his chapter, you should know who needs a scan and who needs a psychiatry referral.

The above chapters lay the groundwork for recognizing psychogenic disorders and classifying them, but finally comes: how do you help these patients? This is complicated as some of them don't seem to want to get better; there is something about the “sick role” that is advantageous over the “well role.” Dr. Michael Clark, who sees some of the toughest cases at Johns Hopkins, and actually seems to really enjoy what he does, guides us through an expert's approach to understanding how such patients got where they are, and how to help them get better.