How Psychogenic is Dystonia? Views from Past to Present

Alexander G. Munts; Peter J. Koehler

Disclosures

Brain. 2010;133(5):1552-1564. 

In This Article

Conclusions

Opinions on whether dystonia is either organic or psychogenic continuously changed on a spectrum between the two extremes over the described period. Genetic studies, the limited efficacy of psychotherapy, the effects of surgical treatments, lesion studies and the recognition that focal dystonias may be minor forms of generalized dystonia pushed the explanatory ideas in the direction of organic. We have seen how insights were influenced by contemporary general pathophysiological concepts (humoral pathophysiology in the pre-1800 period, solid pathophysiology reflected by the clinical-anatomical method thereafter, psychological pathophysiology after about 1900, and genetic and molecular pathophysiology in recent decades), as well as by various research methods, from which we have learnt to be prudent with the interpretation of results and to reflect on epistemological mechanisms. Nevertheless, with these reservations in mind, modern neurophysiological and imaging studies may open new ways for the interpretation of dystonia. In both generalized and focal dystonia, studies point towards abnormalities in the sensorimotor circuitry, resulting in a vulnerable central nervous system. They indicate that the old distinction between psychogenic and organic is not easily applicable and perhaps should be abandoned. Similar mechanisms may be in play in CRPS-related fixed dystonia and sensory and motor disorders in conversion disorder. Hypotheses made on the basis of neurophysiological and functional imaging studies need further testing in these groups of patients. In addition, genetic studies may provide further insight. Until more knowledge is available, we must keep in mind the lessons from history and remember 1975:

In the past, many victims of dystonia and their families have been caused anguish and hardship over and above that caused by the disease itself owing to the frequent misdiagnosis of the symptoms as manifestations of a psychiatric ailment. (Eldridge and Fahn, 1976)

Once hurt, twice shy.

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