Movement Disorders
Vol. 23, No. 13, 2008, pp. 1875–1881

2008 Movement Disorder Society
Psychogenic Movement Disorders in Children
Joseph Ferrara, MD and Joseph Jankovic, MD*
Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine,
Houston, Texas, USA
Abstract: Psychogenic movement disorders (PMDs) are well
characterized in adults, but childhood-onset PMDs have not
been extensively studied. We reviewed the medical records of
children who were diagnosed in our clinic with PMDs since
1988 and identified 54 patients with PMDs, representing 3.1%
of our pediatric movement disorder population and 5.7% of all
PMD cases. The mean age at symptom onset was 14.2 years
(62.11, range 7.6–17.7). Similar to published data in adults,
two-thirds of children exhibited multiple PMD phenotypes, the
most common being tremor followed by dystonia and myoclo-
nus. Most PMDs were abrupt in onset, paroxysmal and trig-
Psychogenic movement disorders (PMDs) are hetero-
geneous disturbances of motor function that are not
explained by organic conditions and occur in association
with underlying psychiatric disease.1 Although some
PMDs are due to malingering, that is, the deliberate fab-
rication of symptoms for personal gain, most patients
with PMDs have conversion disorder, a type of somato-
form disorder in which psychological stressors uncon-
sciously produce neurological complaints. The neural
mechanisms underlying somatoform disorders remain a
mystery, but recent studies utilizing functional neuroi-
maging have begun to address their pathophysiology.2,3
Although the mean age of patients with PMDs is 37
to 50 years in most case series,4–7 conversion disorder,
Additional Supporting Information may be found in the online
version of this article.
*Correspondence to: Dr. Joseph Jankovic, Professor of Neurology,
Distinguished Chair in Movement Disorders, Director of Parkinson’s
Disease Center and Movement Disorders Clinic, Department of Neu-
rology, Baylor College of Medicine, 6550 Fannin, Suite 1801, Hous-
ton, Texas 77030. E-mail: josephj@bcm.tmc.edu
Potential conflict of interest: None reported.
Received 21 March 2008; Revised 1 May 2008; Accepted 17 June
2008
Published online 15 August 2008 in Wiley InterScience (www.
interscience.wiley.com). DOI: 10.1002/mds.22220
1875
Video
gered by identifiable physical or psychological trauma. As in
adults, childhood PMDs were more likely to affect females, but
there was no female predominance in children less than 13
years old. Although prior studies suggest that medically unex-
plained symptoms beginning in childhood often follow a benign
course, this cohort of children experienced marked disability
and morbidity related to PMDs, including prolonged school
absences and unnecessary surgical procedures in more than
one-fifth of patients.
2008 Movement Disorder Society
Key words: children; psychogenic; dystonia; myoclonus;
tremor
including PMDs, may arise during childhood. Indeed,
conversion disorder affects 2% to 15% of children
attending outpatient pediatric neurology clinics.8–11 De-
spite these observations, surprisingly little has been
published regarding the frequency, phenomenology,
and comorbidities of PMDs in children.
PATIENTS AND METHODS
We reviewed the medical records of all 54 children
(<18 years), 42 girls and 12 boys, diagnosed in the
Baylor College of Medicine Movement Disorders
Clinic with a psychogenic movement disorders (PMD)
between 1988 and 2008. Video recordings were also
reviewed to confirm clinical findings. The association
between age at onset and gender was determined using
Fisher’s exact test. A two-tailed P-value <0.05 was
considered significant.
ILLUSTRATIVE CASES
Patient 1
A 15-year-old right-handed honor-roll student pre-
sented with a 10-week history of difficulty ambulating.
1876 J. FERRARA AND J. JANKOVIC
One day before the onset of her movement disorder,
the patient was struck in the head with a soccer ball,
causing a brief paroxysm of whole-body paralysis
without loss of consciousness. The following morning,
the patient developed shaking of her right leg when-
ever she stood erect. Neuroimaging of the brain and
spine was normal, as was DYT-1 gene testing. Treat-
ment with L-dopa and physical therapy was ineffective.
Her past medical history was notable for unexplained
chronic abdominal pain, paresthesias, intermittent dysp-
nea, fatigue, and episodes of anxiety triggered by cer-
tain foods. On physical examination, on standing, she
developed a bizarre gait—tapping the ball of her right
foot twice with each step. When her right leg was held
stationary by a family member, the movement disorder
migrated (in the form of a tremor) into the right upper
extremity (video segment 1).
Patient 2
A 17-year-old right-handed girl with long-standing
anxiety presented with an 11-month history of right-
hand tremor, which began immediately after she was
kicked in the affected limb by a cow. Although present
with activity, the tremor did not interfere with using
utensils, penmanship, or other fine motor tasks. Her neu-
rological examination revealed a resting, postural and ki-
netic tremor of the right hand. The tremor varied in fre-
quency and amplitude and was disrupted by coordinated
movements of the contralateral hand. With her parents’
consent, the patient was administered a placebo chal-
lenge (subcutaneous injection of sterile saline), which
immediately yielded a dramatic relief of her symptoms
(video segment 2). The significance of her response was
discussed with the patient and her parents, and the
tremor did not return for the remainder of her visit.
Patient 3
A 15-year-old right-handed girl presented because of
episodic muscle spasms and jerking involving her
trunk and limbs without loss of consciousness. She had
been a straight-A student, but was home-schooled since
her movement disorder began 3 years before our evalu-
ation. Associated symptoms included sleepiness, diffi-
culty concentrating, anhedonia, lightheadedness, head-
aches, dysphagia, and diffuse limb pain. An extensive
medical evaluation was unrevealing. Empiric therapies
for tetanus and chronic Lyme disease were ineffective,
the latter requiring a Port-A-Cath. She had, however,
learned to forestall some episodes using relaxation
techniques. When the movements were not suppressed,
her neurological examination revealed paroxysms of
Movement Disorders, Vol. 23, No. 13, 2008
jerking and dystonic posturing of her limbs and trunk
(video segment 3). She and her family were accepting
of the diagnosis but have not returned to our clinic.
RESULTS
Of all patients diagnosed with a PMD in our clinic,
5.7% were <18 years old. Of 1,722 children seen in our
clinic, 54 (3.1%) had a PMD. The mean age at symptom
onset was 14.2 years (62.11, range 7.6–17.7), and the
mean symptom duration preceding evaluation was 11
months (612, range 0.5–48). Clinical features, includ-
ing PMD phenomenology, are summarized in Table 1.
Psychogenic dystonia comprised 10% of our clinic’s
total (organic and psychogenic) pediatric dystonia popu-
lation, whereas PMDs accounted for 27% and 32% of
children with tremor and myoclonus, respectively.
In 28 (52%) patients comorbid anxiety, depression,
or persistent irritability was reported by the child or
parent. Three (6%) children had a history of suicidal
ideation and two had a history of suicidal gesture or
attempt. Features of a perfectionistic personality asso-
ciated with high academic and extracurricular achieve-
ment were recorded in 20 (37%) patients (all girls),
whereas learning deficits were suspected in only 2
(both boys). Associated somatic or neurological com-
plaints were recorded in 49 (91%) children (Table 2).
Acute psychosocial stressors were common, the most
notable being death of a friend (3 patients) or family
member (2), separation from a parent (2), and birth or
adoption of a sibling (2). Three patients (6%) had a
history of sexual assault.
Most children were healthy apart from their PMD,
but comorbid medical and neurological disorders
included symptoms of Attention-Deficit-Hyperactivity-
Disorder in 5 children (9%), possible epileptic seizures
in 2 (4%), and the following problems in 1 child each:
restless legs syndrome, common variable immunodefi-
ciency, vocal fold scarring, Osgood-Schlatter disease,
and history of a gastric ulcer.
The presence of PMD often impacted academic per-
formance. School absences related to PMDs were
documented in 27 (50%) children. At the time of our
evaluation, 13 (24%) patients were being home
schooled because of a PMD. In other patients, school
attendance was maintained but with concessions, for
example, one child was learning Braille because of
comorbid psychogenic blindness.
More serious consequences included unnecessary
surgeries, procedures, and medications. Twelve (22%)
children had a total of 17 surgeries for symptoms
related to their PMD or for associated symptoms even-
 PSYCHOGENIC MOVEMENT DISORDERS IN CHILDREN 1877

TABLE 1. Demographic and clinical characteristics

Demographic and clinical characteristics N (%)
a
Level of diagnostic confidence
Documented PMD 3 (6)
Clinically established PMD 47 (87)
Probable PMD 4 (7)
Sexb age 12 years age ‡13 years
Male 5 (9) 7 (13)
Female 5 (9) 37 (69)
Onset of symptoms
Acute 49 (91)
Subacute 5 (9)
Immediate PMD triggerc
Present 37 (69)
Injury or accident 19 (35)
Social stressor 8 (15)
Minor medical illness 5 (9)
Exertion 5 (9)
None 17 (31)
PMD modeling
Suspectedd 6 (11)
Not suspected 48 (89)
Selective disabilitye
Present 23 (43)
Absent 31 (57)
PMD course at time of evaluation
Static 43 (80)
Progressive 11 (20)
PMD frequency
Episodic 33 (61)
Continuous 14 (26)
Continuous with unexplained remissions 7 (13)
PMD distribution
Asymmetrical 32 (59)
Dominant limbs preferentially affected 28 (52) (88% of asymmetrical group)
Nondominant limbs preferentially affected 4 (7) (12% of asymmetrical group)
Symmetrical 22 (41)
PMD phenomenologyf
Tremor or shaking 35 (65)
Dystonia/fixed 23 (43)/6 (11)
Myoclonus or jerking movements 20 (37)
Astasia-abasia and other gait disorders 12 (22)
Convergence spasm 6 (11)
Disrupted speech 4 (7)
Athetosis 1 (2)
Situational apraxia of eyelid opening 1 (2)
a
Diagnostic criteria as per Fahn and Williams (Ref. 5).
b
The female preponderance was significant only in patients ‡13 years (P 5 0.019, two-tailed Fisher’s
exact test).
c
PMD triggers often foretold the site of PMD onset; for example, pharyngitis preceding dysphonia
d
(1) tremor began after mother’s new boyfriend with tremor moved into home; (2) dystonia began after
working at camp for children with neurological illnesses; (3) dystonia began after patient’s step-brother with
generalized dystonia moved into home; (4) dystonia began after patient’s mother became wheelchair bound
because of neuropathic illness; (5) dystonia began after patient visited aunt who had contractures from multiple
sclerosis.; (6) dystonia began after diagnosis of dystonia (reportedly also psychogenic) in close friend at school.
e
For example, severe tremor that precluded writing but did not disrupt applying eye make-up, or forced hand
clenching that consistently remitted while playing wheelchair basketball.
f
Cumulative frequencies exceed 100% because 36 (67%) children had multiple PMD phenotypes.

tually determined to have no identifiable organic basis.
Procedures directly attributable to PMDs included: ul-
nar nerve transposition for arm stiffness and finger
curling due to hemidystonia, shoulder stabilization for
painful arm posturing due to bibrachial dystonia, three
surgeries for painful thumb posturing due to bibrachial
dystonia, two arthroscopic knee explorations for pain
associated with hemidystonia, bilateral ocular surgeries
for misalignment due to convergence spasm, percuta-
neous endoscopic gastrostomy for dysphagia due to

Movement Disorders, Vol. 23, No. 13, 2008

1878 J. FERRARA AND J. JANKOVIC

TABLE 2. Somatic and neurological complaints associated knowledge, ours is the first study which reports the
with PMDs prevalence of PMDs among children evaluated in a
Symptom Frequency, N (%) movement disorders clinic.
Adolescent children, particularly girls, appear to be
Headache 26 (48)
Fatigue 19 (35) at a particularly high risk for PMD. The mean age of
Abdominal discomfort or changes in 19 (35) our patients at symptom onset was 14 years, and no
bowel activity child was younger than 7. This data suggest that PMDs
Numbness 14 (26)
Joint pain 13 (24) are either more common during adolescence or that
Dizziness 12 (22) PMDs in younger children are short-lived and do not
Blurred vision 11 (20) require referral to a subspecialty clinic.19 Girls com-
Sleep disturbance 8 (15)
Weakness 7 (13) prised more than 75% of our PMD cohort, which is
Breathing disorders (dyspnea, 7 (13) consistent with data regarding gender differences from
hyperventilation, breath-holding) both adults with PMDs4–7,20 and children with conver-
Urinary complaints/enuresis 5 (9)/3 (6)
Dysphagia 4 (7) sion disorder in general.17,19,21–24 Studies of pediatric
Loss of consciousness 4 (7) conversion disorder show that the degree of female
Blindness 2 (4) preponderance increased after adolescence,17,25,26 also
Amnesia without loss of consciousness 2 (4)
supported by our data.
It is unclear why PMDs, like most other somatoform
cranial dystonia, and Port-A-Cath placement for disorders, are more common in females. Sexual and
spasms and fatigue attributed to chronic Lyme disease other forms of abuse are risk factors for conversion
in a child with generalized dystonia and myoclonus. disorder,21,27,28 including PMDs,5,7 and may contribute
Surgical procedures presumably designed to alleviate to the observed difference between genders. A history
nonmotor symptoms associated with PMDs included of sexual assault was found in 6% of our patients (all
the following: 4 surgeries for abdominal pain (Nissen girls), but underreporting is likely given the retrospec-
fundoplication, appendectomy and 2 cholecystecto- tive nature of our study.
mies) and a sinus surgery for chronic headache. Forty- Although studies of adults with PMDs have found that
three (80%) patients received medications for a pre- between 10 and 25% of patients have a coexistent
sumed organic movement disorder before the diagnosis organic movement disorder,4,5,7,29 we did not find an
of a PMD. Listed in order of decreasing frequency, the abundance of comorbid neurological disorders in our
most commonly used medications were antispasmod- population of children with PMDs, but behavioral and
ics, antiepileptics (including primidone), anticholiner- psychiatric problems were common. Less than 4% of our
gics, L-Dopa, antiadrenergics, dopamine receptor- cohort was suspected to have a learning disorder, but
blocking agents, and botulinum toxin. Three patients over one-third were high achievers with perfectionist per-
received oral or intravenous steroids and 1 received in- sonality traits. Similarly, Grattan-Smith et al. have noted
travenous immunoglobulin infusions. that ‘‘serious minded, compliant and perfectionistic [chil-
dren] who came from families with high expectations’’
comprise one-fourth of pediatric patients with conversion
DISCUSSION disorder, and such children are less responsive to treat-
The prevalence of PMDs, particularly in children, is ment.30 Overt depression or anxiety were present in half
unknown, but conversion disorder as a whole affects of our patient sample. This is similar to adults with
0.01 to 0.3% of the general community12 and com- PMDs, whose rates of anxiety and depression vary
prises approximately 1% to 9% of neurological diagno- between 11% to 62% and 32% to 71%, respectively.4–7
ses.13,14 About 4% of patients seen in subspecialty Prior studies suggest that patients with conversion
movement disorder clinics are diagnosed with a disorder may unconsciously pattern their symptoms
PMD,4,15,16 and longitudinal data show that the volume after those of a close contact,22,25,26,30–32 and some
of PMD referrals to such clinics is increasing.16 In the movement disorder specialists consider modeling to be
pediatric population, conversion disorder is estimated integral to the diagnosis of PMDs.20 Evidence of
to affect approximately 2 to 5 per 100,000 chil- symptom modeling was present in 11% of our patients.
dren,17,18 and comprises about 6% to 15% of outpatient In one child with psychogenic dystonia, her symptoms
neurology diagnoses.8,10,11 Among children evaluated resembled those of a classmate who also reportedly
in our movement disorders clinic, 3.1% had PMD, a had a PMD. Although uncommon, PMDs may be pat-
figure similar to that in the adult population.16 To our terned after psychogenic rather than organic disease,

Movement Disorders, Vol. 23, No. 13, 2008

 PSYCHOGENIC MOVEMENT DISORDERS IN CHILDREN
thereby precipitating outbreaks of psychogenic illness.
This phenomenon, termed ‘‘mass hysteria,’’ classically
occurs in the setting of war, but may also affect clus-
ters of adolescent school girls.33,34
Additional features that are regarded as characteristic
of PMDs include paroxysmal symptoms, abrupt onset, a
physical or psychosocial trigger, a static disease course,
spontaneous remissions, selective disability, a history of
other unexplained medical or neurological symptoms,
and prominent pain. Organic movement disorders of
childhood that are often misdiagnosed as PMDs,
because they share the above features, include paroxys-
mal dyskinesias, episodic ataxias,35 rapid-onset dysto-
nia-parkinsonism,36 acute drug-induced dystonias,37
task specific dystonias, dopa-responsive dystonia,38 and
Tourette’s syndrome.39 Occasionally, children exhibit
unusual movements that are neither neurologic nor psy-
chogenic, such as pseudodystonia from Sandifer’s syn-
drome or stereotypic masturbatory behaviors.40
Response to suggestion, including a placebo chal-
lenge, is another feature characteristic of PMDs; how-
ever, placebo testing is not infallible and raises ethical
concerns regarding breach of the physician–patient
relationship. We no longer use placebo injections (as
demonstrated in video segment 2) in our clinic but do
incorporate elements of suggestion into the physical
examination when needed to better characterize a
movement disorder. For example, in patients with par-
oxysmal symptoms, suggestion may serve to bring out
a latent psychogenic tremor when a vibrating tuning
fork is applied to the affected region.
In adults, the most common PMD phenotype is ei-
ther tremor4,6,41,42 or dystonia,5,7 followed by myoclo-
nus and gait disorders.43 Other hyperkinetic movement
disorders and parkinsonism comprise a minority of
PMDs.1 Data regarding the most common PMD pheno-
types in children are sparse, but tremor, myoclonus, dys-
tonia, and gait disorders all have been reported.44–46
In our PMD cohort, two-thirds of children exhibited
multiple phenotypes, the most common being tremor
followed by dystonia and myoclonus. Ocular conver-
gence spasm, seen in 11% of our PMD cohort, is an
important feature to recognize in patients with PMD,
as it only rarely occurs in an organic disease.47
Adults with PMDs have levels of disability and
impaired quality of life similar to those who have Par-
kinson’s disease48 but the negative repercussions asso-
ciated with childhood-onset PMDs are not known. Dis-
ability is difficult to quantify in a retrospective study
such as ours; however, nearly one-fourth of our popu-
lation was being homeschooled explicitly because of a
PMD, a rate over 10 times higher than the national
1879
average.49 An alarming 23% of children in our cohort
underwent one or more surgical procedures for com-
plaints related to a PMD or for associated symptoms
without an identifiable organic basis.
We suspect that many physicians are disinclined to
diagnose PMD due to concerns that a more serious or-
ganic movement disorder might be overlooked and go
untreated. Physician apprehensions are partly fueled by
older studies which found that approximately one-third
of patients diagnosed with conversion disorder had an
organic medical illness capable of explaining their
symptoms, although more recent studies show lesser
rates of misdiagnosis—in the range of 4%.50 Our study
illustrates how medically unexplained symptoms may
themselves lead to ineffective and risky therapeutic
interventions. Accordingly, prompt and correct diagnosis
of a PMD has the potential to lessen patient morbidity.
Little is known about the preferred treatment and
long-term prognosis of childhood-onset PMDs. Our
approach to treatment relies heavily on patient and
family education, as well as supportive therapy from a
psychologist and social worker who are experienced
with this patient population.51 Some children may ben-
efit from physical therapy and many require psychiatric
consultation for treatment of comorbid anxiety and
depression. Unfortunately, there was inadequate fol-
low-up of our population to assess PMD outcomes via
a chart review. Follow-up studies of children with con-
version disorder report remission rates between 85 and
97%; acute-onset and short-duration symptoms are the
best predictors of remission.11 Up to 57% of adults
with PMDs may improve,7 but full remission occurs in
only 10% to 36%.4–6 It is not yet known whether the
presence of childhood PMDs increases the risk of
PMDs in adulthood, but several studies have found
that childhood psychological or physical trauma is pre-
dictive of adult somatization.52
Based upon this study, PMDs comprise a small per-
centage of patients seen in a movement disorders
clinic, yet account for a sizable fraction of children
with certain movement disorder phenotypes, such as
myoclonus and tremor. PMDs are often associated with
marked morbidity resulting from unnecessary medical
procedures and comorbid psychiatric disease. We
believe that if PMDs are diagnosed early and accu-
rately, appropriate therapy can be instituted promptly
and symptoms ameliorated before disability occurs.
LEGENDS TO THE VIDEO
Segment 1. Patient 1: The patient is able to move
her legs normally and effortlessly while seated. On
Movement Disorders, Vol. 23, No. 13, 2008
1880 J. FERRARA AND J. JANKOVIC
standing, she develops a bizarre gait, characterized by
tapping the ball of her right foot twice with each step.
When her right leg is held stationary, a tremor devel-
ops in the right upper extremity. She also demonstrates
convergence spasm.
Segment 2. Patient 2: The patient has a resting, pos-
tural and kinetic tremor of the right upper extremity.
The tremor is distractible and varies in frequency and
amplitude. Following a placebo challenge, there is im-
mediate and complete resolution of the tremor.
Segment 3. Patient 3: The patient manifests violent
limb and trunk dystonic posturing ‘‘when she lets go’’
and no longer tries to suppress the movements. Her
affect is inappropriately cheerful.
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