CME INDIA Case Presentation by Dr N. K. Singh, Dhanbad.
CME INDIA Case Study
CASE: Diabetic, on Dapagliflozin, Gilmipiride, Metformin and Tenaligliptin. Random sugar 150 mg. For low back pain MRI advised. When JUST Inside MRI, got panicky and was taken out immediately. Since then this happening. Four days after consultation made. What is this? What to do?
CME INDIA Discussion:
Dr Ashish Dengra, Jabalpur: Is she taking lesuride / domperidone it looks like extrapyramidal symptoms.
Dr N. K. Singh: Not on lesuride or domperidone.
Dr Ashish Dengra, Jabalpur: Sodium.
Dr N.K. Singh: Not done.
Dr DP Khaitan, Gaya: Situational Panic attack.
Dr Ujjawal Roy, DM, Neuro, Ranchi: Its dyskinesia of lip.Numerous causes. Any drug history?
Dr Abhishek, DM, Neuro, Patna: Lip tremor, not a typical dyskinesia. Looks like psychological.
Dr N.K. Singh: Looks Like …. Clonazepam given, movement disappeared.
Dr Ujjawal Roy, DM, Neuro, Orchid Ranchi: Once u rule out everything then only psycogenic should be considered – thats a thumb rule. Because in dress of psycogenic many movement disorders remain masked. 😃 Thats quite common. It can be psycogenic, there is no doubt about it. But first rule out other things.
Dr Abhishek, DM, Neuro, Patna: It developed just after going in to MRI machine… In these situation issue, first try benzodiazepines. If no improvement, then only work up.
Dr Ujjawal Roy, DM, Neuro, Orchid Ranchi: Oh, if only after visiting MRI, definitely may be psycogenic. But still before labelling we should have detailed history, whether any previous episodes etc.
Dr Anil Kumar, pshy, Ranchi: Conversion reaction will respond to clonazepam.
Dr Sunendra Kumar, DM, Neuro, Ranchi: Also, tests of suggestion like patch test can be tried. Patient should be engaged in some normal conversation and then her movements should be observed while conversation. Sometimes these simple non-pharmacological manoeuvres can help… But even with pseudoseizures we should go for MRI brain and EEG to rule out any structural cause…. Very interesting case and interesting finding….
Dr Ashok Kumar, DM, Neuro, Ranchi: History — temporal association with a stressful investigation, possible claustrophobic fear – suggests psychogenic causation. BUT, examination reveals – Stiff upper lip, highly localised rapid tremor of only lower lip bilateral and absence of jaw movements. We get hints of upper face masking. While it could be psychogenic, an extrapyramidal origin must be sought. Response to clonazepam cannot rule out extrapyramidal disease. Needs further History, examination for tremors elsewhere as well as rigidity and other signs.
Dr Anil Kumar Psychiatrist, Ranchi: Psychogenic lip tremors. Such types of rthymic movements are unusual that’s why confusion. Reported as rabbit tremor or dyskinesia. Rabbit tremor occurs after short duration of antipsychotic and orophyrangeal dyskinesia after prolonged use of antipsychotics. In this case duration is very short movements don’t resemble acute dyskinesia so it is psychogenic by taking good history.
Provisional Diagnosis:
Psychogenic lip tremors
What You think?
CME INDIA Learning Points:
1.The theory of Mind
- Patients with functional tremor exhibit altered emotion processing circuitry.
- There is increased activation in the paracingulate gyrus after emotional stimuli.
- Increased connectivity between the left amygdala and middle frontal gyrus
- Functional disorders may be associated with disturbances in the theory of mind.(Alberto J et al https://doi.org/10.1016/j.nicl.2017.10.020)
2. Psychogenic movement disorders are characterized by unwanted movements, such as spasms, shaking or jerks involving any part of the face, neck, trunk or limbs. History is the most vital in making diagnosis.
3. Most psychogenic movements are considered involuntary – performed without conscious awareness or effort. They can mimic organic movement disorders, such as tremor, dystonia, myoclonus, parkinsonism, tics and paroxysmal dyskinesias.
4. The diagnosis is based on a combination of a number of clinical observations and recognition of typical characteristics (phenomenology) that include, but are not necessarily limited to the following:
- Onset of the movements is abrupt/sudden.
- Movements are triggered by emotional or physical trauma, or by some conflict (marital, sexual, work-related).
- Movements are episodic or appear intermittent.
- There are spontaneous remissions of the movements.
- Movements disappear with distraction.
- Movements are suggestible, meaning they may disappear by making a suggestion. For example, suggesting that the application of a tuning fork to the body part affected may help relieve the movements.
- Underlying psychiatric disturbances (depression, anxiety) are present.
- There are multiple somatizations and undiagnosed conditions.
- There is a lack of emotional concern about the disorder (“la belle indifference”).
- There has been exposure to neurologic disorders during one’s occupation (e.g. nurse, physician) or while caring for someone with similar problems.
5. Making the diagnosis of a psychogenic movement disorder is a two-step process. First is to make a positive diagnosis that the movements are psychogenic rather than from an organic illness. Second is to identify either a psychiatric disorder, such as depression or anxiety, or the psychodynamics that could explain the abnormal movements. It is very important to make the correct diagnosis when it is a psychogenic movement disorder because only then can appropriate treatment be started.
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Appears to be Psychogenic
Past & Family history also to be taken
Less likely to be organic