JNNP Online First, published on February 5, 2013 as 10.

1136/jnnp-2012-304062
Movement disorders

SHORT REPORT

Transcranial magnetic stimulation as an efficient

treatment for psychogenic movement disorders
Béatrice Garcin,1,2,3 Emmanuel Roze,1,3 Francine Mesrati,4 Emmanuel Cognat,1
Emmanuel Fournier,4 Marie Vidailhet,1,3 Bertrand Degos1,5

▸ Additional material is ABSTRACT PATIENTS AND METHOD

published online only. To view Background Management of psychogenic movement The study was approved by the local ethics
please visit the journal online
(http://dx.doi.org/10.1136/
disorders (PMDs) is challenging for neurologists and, committee. We included 24 consecutive inpatients
jnnp-2012-304062). to date, there is no consensus about their treatment. with PMD admitted between December 2010 and
1 Recent studies suggested a possible therapeutic effect October 2011 to the movement disorders unit of
Département de Neurologie,
Hôpital Pitié-Salpêtrière, Centre of repeated transcranial magnetic stimulation (TMS) in Salpêtrière Hospital for investigation and/or treat-
de Référence Maladie de psychogenic paralysis and tremor. ment of abnormal movements. All patients fulfilled
Parkinson, APHP, Paris, France
2
Objective To document the clinical impact of TMS in the criteria for clinically established PMD, as
Service de Neurologie, Hôpital PMDs. defined by Fahn and Williams.1 The diagnosis was
Saint Antoine, APHP, Paris,
France
Methods We blindly video scored symptoms of made by one movement disorder expert and con-
3
Institut du Cerveau et de la consecutive patients with PMD who were recorded firmed by at least one other movement disorder
Moelle, Inserm UMR_S 975; before and after TMS. TMS was delivered at low expert from our centre. Except for one Italian
CNRS UMR 7225, CR-ICM— frequency (0.25 Hz) over the motor cortex contralateral patient (case no 22), all the other patients were
UPMC, Paris, France
4 to symptoms. seen at least once (mean 2.2±2 times, range 1–10;
Département de
Neurophysiologie Clinique, Results Twenty-four patients were included. They median 1, IQR 1–3) by a movement disorder
Groupe Hospitalier presented with dystonia, myoclonus, tremor, specialist from our unit at least 1 month before
Pitié-Salpêtrière, APHP, Paris, Parkinsonism or stereotypies. The median duration of low-frequency repeated TMS. All were followed up
France symptoms before TMS was 2.8 years (6 months to for a median duration of 6 months before the TMS
5
Center for Interdisciplinary
Research in Biology, INSERM 30 years). The overall score of 75% of patients improved session (IQR 3–10; mean 10.9±13, range 1–40).
U-1050, Collège de France, by >50% and, furthermore, the clinical benefits were All patients gave written informed consent for a
UPMC, Paris, France sustained upon protracted follow-up (median video and the TMS.
19.8 months). There was no correlation between The patients were given information about the
Correspondence to
improvement and duration of symptoms before TMS. three following aspects of the procedure. First,
Dr Bertrand Degos,
Département de Neurologie, Conclusions TMS is a therapeutic option for PMDs, their symptoms were explained as being a conse-
Hôpital de la Salpêtrière, including chronic PMDs. quence of brain dysfunction in the absence of
47–83 bd de l’Hôpital, lesion of the motor system and that, although
Paris cedex 13 75651, France; unconscious, it was often linked to a psychological
bertrand.degos@psl.aphp.fr
INTRODUCTION difficulty. Second, they were informed that the
Received 31 August 2012 Psychogenic movement disorders (PMDs)1 account integrity of the motor system would be assessed
Revised 14 December 2012 for about 0.3% of all patients seen in neurology and confirmed with motor evoked potentials,
Accepted 9 January 2013 clinics and 3% of those seen in movement disorder resulting in reduced and/or disappearance of symp-
clinics.2 3 Diagnosis and management of PMDs toms upon repeated TMS. Third, TMS was
remains challenging. Symptoms can mimic the full described to the patients as a very efficient treat-
range of organic abnormal involuntary movements— ment with excellent results. Patients were video-
psychological or psychiatric disturbances being not taped the day before and the day after the TMS
always obvious. The outcome is often poor, since session. After treatment and putative recovery, we
only half of the patients improve after 3 years of recommended the patients to undergo physiother-
follow-up,4 with a significant related disability, similar apy. We further advised them to be followed up by
to that seen in neurodegenerative conditions.5 a psychologist or a psychiatrist to identify the
Multidisciplinary care is often proposed for these origin of the trouble and/or to discuss the physical,
patients but there is an overall lack of data, recom- psychological, social and professional impacts of
mendations and consensus about the management of the motor benefits induced by the TMS. No drugs
PMDs.6 were added to this care management. We made it
Low-frequency repeated transcranial magnetic clear before the therapeutic TMS session that the
stimulation (TMS) was recently proposed to treat psy- neurological follow-up by a neurologist would not
chogenic paralysis, showing encouraging results.7 be interrupted, even after putative disappearance of
A preliminary study also suggested its efficiency in the symptoms.
To cite: Garcin B, Roze E, psychogenic tremor.8 However, a recent study Somatosensory and motor evoked potentials
Mesrati F, et al. J Neurol showed no efficacy of repetitive TMS using stimula- were performed before TMS treatment, ensuring
Neurosurg Psychiatry
Published Online First:
tion under motor threshold in five patients with the sensory and motor tract integrity in all cases.
[please include Day Month chronic PMDs.9 Therefore, in view of these conflict- Then, an average of 20 stimuli (120% of the
Year] doi:10.1136/jnnp- ing results, we conducted a prospective pilot study to resting motor threshold; each stimulus lasted for
2012-304062 test its effect in patients with PMD. 250 ms) were delivered at low frequency (0.25 Hz)

Copyright
Garcin Article
B, et al. J Neurol author
Neurosurg (or2013;0:1–4.
Psychiatry their employer) 2013. Produced
doi:10.1136/jnnp-2012-304062 by BMJ Publishing Group Ltd under licence. 1
 Movement disorders

with a circular coil (9 cm diameter, Magstim device) over the All statistical analyses were performed with GraphPad Prism
motor cortex either contralaterally to symptoms—or bilaterally, software, with a threshold set at p<0.05 for significance.
if movement disorders were bilateral. The stimulation intensity Spearman’s rank correlation test was used for correlation ana-
was sufficient to induce a motor response. To evaluate the sever- lyses. A Student t test was used for comparison of two groups,
ity of the wide range of movement disorders seen, we designed after checking for variance similarity with Fisher’s test, and an
a rating scale based first, upon a modified version of the analysis of variance was performed to compare scores across
Abnormal Involuntary Movement Scale,10 and second, upon more than two groups. Results are expressed as percentage and
the walking subscore of the disability score from the Burke– as mean±SD.
Fahn–Marsden Scale (see online supplementary material).11
Overall scores on our scale ranged from 7 (normal) to 41 RESULTS
(worst score). Twenty-four patients (16F/8M) were included in the cohort.
To objectively assess the efficiency of TMS, two movement dis- The main characteristics of the population are displayed in
order specialists (BD and EF-R) blindly rated the patients table 1. The mean age of patients was 44.5±13.2 years (range
recorded before and after repetitive TMS. Three cases required 22–76 years). They had fixed dystonia (46%, N=11), myoclo-
an additional evaluation (by MV) owing to a scoring discrepancy nus (21%, N=5), tremor (12.5%, N=3), jerky dystonia (12.5%,
>10%. Scores were then averaged to compare scores before and N=3), Parkinsonism (4%, N=1), or stereotypies (4%, N=1).
after TMS. Furthermore, to assess the continuing effectiveness of The median duration of the symptoms was 2.8 years (mean dur-
TMS a self-evaluation of the clinical status was conducted by tele- ation 6.8 years±8.9; range 0.5–30 years). Seven patients (29%)
phone 1 year after the end of the inclusion period (November had psychiatric comorbidities, which were chronic depression
2012) using the Clinical Global Impression—Improvement Scale (N=4), bipolar disorder (N=2) or addiction to drug of abuse
(CGI-I Scale)12; this scale ranges from 1 (very much improved) to (N=1). At the time of TMS treatment, 14 patients were taking
7 (very much worse) and includes 0 (not assessed). no specific medication, while the 10 remaining patients were

Table 1 Main clinical characteristics of the 24 patients included in the study

Duration Number of
before Duration of relapses
Age at repeated TMS Efficiency follow-up (efficiency of
Patient treatment Psychiatric Movement treatment on total (months)/CGI following
number Gender (years) comorbidities disorder Body region Onset (years) score (%) score* repeated TMS)

1 F 60.0 Bipolar Jerky dystonia UL Sudden 0.5 72.2 10.1/0 3 (+)

2 F 30.6 Depression Dystonia Left side Sudden 9.9 96.3 21.7/1 0
3 M 49.8 No Myoclonus Neck+UL Progressive 4 100.0 22/5 2 (+)
4 F 60.6 No Dystonia Right side Sudden 0.7 89.3 21.3/1 2 (+)
5 M 38.9 No Parkinsonism Whole body Subacute 25.2 57.6 19.9/2 0
6 M 43.9 No Dystonia Left side Subacute 3.5 37.7 18.3/4 0
7 M 38.2 Drug abuse Jerky dystonia Whole body Subacute 1.7 53.3 23.1/2 1 (+)
8 F 32.9 No Dystonia UL+LL Progressive 22 36.4 34.6/2 4 (+)
9 F 57.3 Depression Jerky dystonia Hands Progressive 30.2 50.0 19.2/3 1 (+)
10 M 54.2 No Dystonia Left UL Sudden 3.2 100.0 19.4/1 0
11 F 24.2 No Dystonia Right hand Sudden 2.4 100.0 19.7/1 1 (+)
12 F 53.0 No Dystonia Right LL Subacute 1.1 37.5 19.4/1 0
13 F 21.9 No Dystonia Right UL Progressive 3 100.0 22/2 0
14 F 34.7 No Dystonia Trunk and LL Sudden 2.5 100.0 19.7/3 2 (+)
15 F 75.9 Depression Myoclonus LL Subacute 1.3 62.5 17.6/6 0
16 F 43.6 Bipolar Dystonia LL Progressive 1.9 10.5 23.1/4 0
17 F 47.4 Depression Tremor Right UL Subacute 2 100.0 21.7/2 0
18 F 35.8 No Tremor UL Progressive 23.3 73.3 18.5/2 2 (+)
19 F 25.0 No Dystonia Right UL Sudden 11.8 75.0 23.1/3 3 (+)
20 M 55.6 No Myoclonus Trunk+LL Progressive 0.7 26.9 27.3/4 1 (+)
21 F 51.3 No Stereotypies UL+LL Progressive 3.7 17.9 25.4/3 0
22 M 56.7 No Myoclonus Trunk+LL Sudden 1.4 88.2 14.6/2 0
23 F 40.2 No Myoclonus UL+LL Sudden 0.7 59.3 1.9/0 0
24 M 35.5 No Tremor Whole body Subacute 6.8 51.9 12.8/3 4 (+)
Median 43.7 2.8 67.4 19.8/2
Mean 44.5 6.8 66.5 19.9/2.6
Sudden, in <24 h; subacute, 24 h–1 month; progressive, >1 month.
+, positive effect of the low-frequency repeated TMS.
*CGI score performed at the end of follow-up. CGI-I=1, very much improved; CGI-I=2, much improved; CGI-I=3, minimally improved; CGI-I=4, no change; CGI-I=5, minimally worse;
CGI-I=6, much worse; CGI-I=7, very much worse.
CGI, Clinical Global Impression; LL, lower limbs; TMS, transcranial magnetic stimulation; UL, upper limbs.

2 Garcin B, et al. J Neurol Neurosurg Psychiatry 2013;0:1–4. doi:10.1136/jnnp-2012-304062

 Movement disorders

one-third (N=6) had a complete resolution of motor symp-

toms. After a median follow-up of 19.8 months, 17 patients
were still improved and the effect was sustained in half of the
cases (N=12; CGI-I=1 or 2). The rate of post-TMS improve-
ment could not be significantly correlated with any prior clin-
ical parameter (including symptom duration).
Our 24 patients share common characteristics with previous
cohorts reported in the literature2: (i) a mean age at onset of 40–
50 years, (ii) a clear female predominance, (iii) dystonia, myoclo-
nus and tremor were the most common movement disorders. It
is noteworthy that all the PMDs of our study were defined as
chronic because abnormal movements lasted for at least
6 months (median duration 2.8 years, range from 6 months to
Figure 1 Improvement of patients with transcranial magnetic 30 years). A negative prognostic value is usually assigned to long-
stimulation (TMS). The chart represents the percentage of patients who
lasting symptoms (>6 months).2 By contrast, our patients
were improved by ≥75%, 50–75%, 25–50% and <25%.
improved after TMS sessions despite longlasting symptoms, and
the influence of symptom duration could be further ruled out.
receiving various treatments for their movement disorder, Recent studies reported a possible beneficial effect of low-
including antidepressant agents (N=6), clonazepam (N=5), frequency TMS in psychogenic paralysis7 and in psychogenic
antiepileptic medication (N=2) and/or baclofen (N=2). tremor.8 Accordingly, our data support the suggestion that TMS
The clinical score of all patients improved upon TMS treat- may be a valuable therapeutic option in a wide range of PMDs,
ment. After low-frequency repeated TMS, 75% of the patients even in patients with chronic symptoms. The pathophysiology
(N=18) improved by >50% and, among them, one-third of PMDs and the mechanisms by which TMS may improve the
(N=6) had a complete resolution of motor symptoms (figure 1). symptoms remain unclear. Recent neurophysiological studies
The improvement occurred immediately after the session in all suggest that somatosensory inputs are altered in psychogenic
cases. No side effects were seen. We observed no correlation dystonia.6 13 While the beneficial effect of TMS might be due
between TMS efficiency and subsequent duration of symptoms to the combination of suggestion/placebo and unknown cortical
(r=0.0004, p value (two-tailed)=0.99), gender (t=0.24, df=22; functioning effects, we consider that the repeated low-frequency
p value (two-tailed)=0.81), age (r=0.21, p value (two-tailed) TMS (below 1 Hz) used in this study could not be responsible
=0.32), clinical presentation (F=0.65, p value (two-tailed) for stimulation-induced after-effects because (i) stimulation of
=0.63), use of medication (t=0.7, df=22; p value (two-tailed) the motor cortex at 0.1 Hz for 1 h did not change cortical excit-
=0.49) or psychiatric comorbidities (t=0.31, df=22; p value ability,14 (ii) at 1 Hz, a minimum of 750 TMS pulses was
(two-tailed)=0.76). needed to modulate motor-evoked potential amplitude from 0
There was a high rate of concordance between raters to 15 min after the intervention, whereas 600 TMS stimuli at
on ranking patients’ overall PMD burden. The Spearman 1 Hz failed to modulate flexor carpi radialis H reflex15; which is
correlation for the total PMD scores between the two raters was well above the total number of pulses we delivered to our
0.93. Kendall’s concordance coefficient for the total PMD patients. All stimuli were above motor threshold.
rating score was 0.83 and the intraclass correlation coefficient Movements induced by TMS altered PMD for a few seconds.
was 0.93. Thereby, the patients could discover for themselves the possibil-
The median duration of follow-up was 19.8 months (N=24; ity of transiently modifying the abnormal movement/posture.
IQR 18.5–22.3). At the last follow-up, 17 patients (71%) felt During the TMS session, FM discussed this positive motor phe-
improved (ie, CGI-I<4). Of these, 12 were much improved or nomenon and thereby provided synergistic psychological
very much improved (ie, CGI-I=1 or 2). Three patients were reinforcement. There might be a cognitive-behavioral, rather
stable in comparison with baseline (ie, CGI-I=4), two patients than placebo, effect when patients see an unexpected alteration
felt worse (ie, CGI=5 or 6), and two patients were lost to of their movement disorder. This, combined with suggestion,
follow-up (ie, CGI-I=0, case nos 1 and 23). The median CGI could be a powerful stimulus inducing change in belief about
score was two (N=22; range 1–6). Ten patients (42%) relapsed symptoms and could trigger or help recovery.
during the follow-up period but after new TMS sessions they Acknowledgements We thank Arlette Welaratne for her help in the preparation
had all improved as much as after the first session. Finally, 12 of of the video. We thank Yorick Gitton for editorial suggestions. The research leading
the patients among those whose score had improved by >50% to these results has received funding from the programme ‘Investissements d’avenir’
(N=18) still displayed remarkable improvement at the end of ANR-10-IAIHU-06.
follow-up, as assessed by a score of 1 or 2 on the CGI-I scale. Contributors BG, BD, EC and ER were involved in conception, organisation and
Four of them (case nos 5, 10, 18 and 19) even returned to work execution of the research project, and writing of the first draft of the manuscript.
In addition, BD was involved in the coordination and supervision of the project and
after TMS treatment. manuscript. FM was involved in execution of the research project
(electrophysiological explorations), and manuscript review and critique. EF and MV
were also involved in manuscript review and critique.
DISCUSSION
Funding The research leading to these results received funding from the
TMS should be considered as a therapeutic option for chronic programme ‘Investissements d’avenir’ ANR-10-IAIHU-06.
PMDs, in addition to the standard clinical care. This is
Competing interests None.
important for clinical practice since management of PMDs is
difficult, time-consuming and often costly for society. Of 24 Patient consent Obtained.
consecutive patients with various PMDs, 75% (N=18) halved Ethics approval Local ethic comittee: comité de protection des personnes de
their severity score immediately after the application of low- l’hopital Pitié Salpêtrière.
frequency repeated TMS over the motor cortex. Of these, Provenance and peer review Not commissioned; externally peer reviewed.

Garcin B, et al. J Neurol Neurosurg Psychiatry 2013;0:1–4. doi:10.1136/jnnp-2012-304062 3

 Movement disorders

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4 Garcin B, et al. J Neurol Neurosurg Psychiatry 2013;0:1–4. doi:10.1136/jnnp-2012-304062