Dystonia induced by peripheral trauma: organic or psychogenic?

Distonia induzida por trauma periférico: origem orgânica ou psicogênica

LETTERS

Dystonia induced by peripheral trauma: organic or psychogenic?

Distonia induzida por trauma periférico: origem orgânica ou psicogênica

Denise H. Nicaretta^I; Ana Lucia Rosso^II; James P. de Mattos^II; Leonardo Brandão^I; Maria Lucia V. Pimentel^I; Sergio A.P. Novis^I,II

^I25ª Enfermaria da Santa Casa de Misericórdia do Rio de Janeiro, Rio de Janeiro RJ, Brazil

^IIServiço de Neurologia Prof. Sergio Novis, Hospital Universitário Clementino Fraga Filho (UFRJ), Rio de Janeiro RJ, Brazil

^{Correspondence}

Dystonia is defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures. A cause-and-effect relationship between brain injury and subse-quent movement disorder is well established, but a link with peripheral trauma is more controversial¹. Our ob-jective is to discuss the challenge of the differential diag-nosis between organic or psychogenic dystonic posture in a patient with post-traumatic hand dystonia.

Patient

A 16-year-old right-handed girl developed an ab-normal posture of the right hand one week after a fall. The symptoms got steadily worse and a fixed posture (flexion and subluxation of the third and fourth right fingers, flexion and aduction of the right thumb and flexion of the right wrist) soon developed with complete loss of function of the hand. Oral drug treatment was ineffective. After four subsequent applications of bot-ulinum toxin type A she was able to move her thumb and partially her second and third fingers. She required a three-step surgical approach due to subluxations over 17 months. MRI of the brain and right brachial plexus were normal. The patient has a stable moderate improvement of the symptoms. Many subsequent psychiatry evalua-tions failed to disclosure any psychiatric disturbances. Three years later she had another trauma on the right shoulder but did not developed any movement disorder.

In 2001, Jankovic² proposed the following criteria for the diagnosis of peripherally induced movement dis orders: [1] the trauma is severe enough to cause local symptoms for at least two weeks; [2] the initial manifes-tation of the movement disorders is anatomically related to the site of injury; [3] the onset of the movement disor-ders is within days or months (up to one year) after the injury. On the other hand, clues to the diagnosis of psy-chogenic dystonia, according to Fahn and Williams³ are: [1] sudden onset; [2] spontaneous remissions; [3] par-oxysmal occurrence; [4] change of frequency, amplitude and pattern; [5] distractibility; [6] inconsistent and in-congruous movements; [7] beginning as a fixed posture; [8] response to placebo, suggestion or psychotherapy.

Our patient fulfilled all of the Jankovic's criteria for the diagnosis of organic dystonia induced by peripheral trauma, that is: severe injury; anatomical relationship to the site of injury; and onset one week after the trauma. Its pathophysiology is not fully understood; however, several evidences suggest that an asymptomatic under-lying dysfunction of the central nervous system plays a significant role in this abnormal movement^2,4. In spite of considering this an organic movement, it is important to remember that complete recovery is rare² after surgical intervention in organic dystonia and so it could reinforce a probable psychogenic origin. If we take into account the sudden onset, the fixed posture and the incongruous movement, all are in favor of a psychogenic dystonia. In contrast this patient never had a history of an affective disorder. A clear diagnostic is often difficult to establish but we believe that our patient has an organic origin al-though she had unusual features.

In summary, our patient fulfilled Jankovic's criteria for the diagnosis of organic dystonia induced by periph-eral trauma; however, recovery is exceptional after sur-gical intervention in organic dystonia. We should em-phasize the great difficulty on the differential diagnosis between organic and psychogenic dystonia.

Received 19 January 2011

Received in final form 18 February 2011

Accepted 28 February 2011

• 1. Jankovic J. Post-traumatic movement disorders: central and peripheral mechanisms. Neurology 1994;44:2006-2014.
• 2. Jankovic J. Controversy: can peripheral trauma induce dystonia and other movement disorders? Yes! Mov Disord 2001;16:7-12.
• 3. Fahn S, Williams DT. Psychogenic dystonia. Adv Neurol 1998;50:431-455.
• 4. Jankovic J, Van Der Linden C. Dystonia and tremor induced by peripheral trauma: predisposing factors. J Neurol Neurosug Psychiatry 1988;51:512-519.

Publication Dates

• Publication in this collection
  19 July 2012
• Date of issue
  June 2011