How Psychogenic is Dystonia? Views from Past to Present

Alexander G. Munts; Peter J. Koehler


Brain. 2010;133(5):1552-1564. 

In This Article

Abstract and Introduction


In the last few centuries, there has been a constant sway between organic and psychogenic explanations for dystonia. In the current study, we investigate this history, assuming the perspective of a spectrum from organic to psychogenic, between which ideas were moving. We have focussed on (i) primary generalized dystonia, (ii) cervical dystonia, (iii) writer's cramp and (iv) fixed dystonia related to complex regional pain syndrome. We have studied medical texts published since the 19th century and their references. Jean-Martin Charcot advocated the concept of hysteria, disorders in which, besides predisposition, environmental factors were involved in their pathogenesis. Sigmund Freud introduced psychoanalysis as an explanatory therapy for psychic disorders. Previous theories, together with the lack of an organic substrate for dystonia, made a strong case for psychogenic explanations. Consequently, many dystonia patients were told that they suffered from psychological conflicts and were treated for them. However, after the description of new hereditary cases in the 1950s, the limited efficacy of psychotherapy in torsion dystonia, the effects of surgical treatments and the lesion studies in the 1960s, more physicians became convinced of the organic nature. The culminating point was the discovery of the DYT1 gene in 1997. In the meantime, experts had already convinced the neurological community that cervical dystonia and writer's cramp were focal dystonias, i.e. minor forms of generalized dystonia, and therefore organic disorders. In contrast, the pathophysiology of fixed dystonia related to complex regional pain syndrome remained controversial. Knowledge of this history, which played on the border between neurology and psychiatry, is instructive and reflects the difficulty in discriminating between them. Today, new insights from functional imaging and neurophysiological studies again challenge the interpretation of these disorders, while the border between psychogenic and organic has become more blurred. Abnormalities of sensorimotor integration and cortical excitability that are currently supposed to be the underlying cause of dystonia bring us back to Sherringtonian physiology. We suggest that this may lead to a common explanation of the four afflictions of which we have traced the history.


For many years, physicians have observed and discussed the remarkable signs of what we nowadays call dystonia. The introduction of the term dystonia as an abnormality of tone with coexistent hypo- and hyper-tonia goes back to 1911, when the well-known Berlin neurologist Hermann Oppenheim (1858–1919) introduced dystonia musculorum deformans, which was later renamed early-onset generalized torsion dystonia (Oppenheim, 1911). In 1967, Wolfgang Zeman (1921–2001) and Paul Dyken reported the presence of milder forms of dystonia in dystonia musculorum deformans families, including cases of isolated writer's cramp (Zeman and Dyken, 1967). In 1976, David Marsden (1938–1998) proposed the term focal dystonia for blepharospasm, oromandibular dystonia, dystonic writer's cramp and torticollis, as well as for axial dystonias, arguing that these were closely related to generalized dystonia (Marsden, 1976). Up to the present, this view has not changed. Over the years, however, there has been discussion on whether the aetiology of dystonia is either organic or psychogenic. In this paper we study the evolution of ideas with respect to dystonia, in particular whether or not it was considered an organic or psychogenic affliction. We will put the historical evolution against the background of present-day knowledge resulting from functional imaging and neurophysiological studies, and of the blurred border between organic and psychogenic.


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