Psychogenic blepharospasm: a diagnostic dilemma

Soumitra DAS*, Roopchand Pandrantil SREEDHARAN, Prasanth Sudhakaran REMADEVI,Cheruvallil Velayudhan SAJI

•Case report•

Psychogenic blepharospasm: a diagnostic dilemma

Soumitra DAS1*, Roopchand Pandrantil SREEDHARAN2, Prasanth Sudhakaran REMADEVI3,Cheruvallil Velayudhan SAJI3

Blepharospasm, psychogenic, movement disorder, functional disorder, India

1. Introduction

Blepharospasm is a movement disorder produced by various well documented causes.[1]The patient is often functionally blind in severe cases. Our patient presented with disabling blepharospasm lasting for hours. The evaluation revealed psychosocial stressors and mild depression. The condition was relieved with suggestion techniques. Psychogenic blepharospasm is a rare entity and only a few cases are reported worldwide.[1,2]Consideration of such aetiology should be done in an atypical presentation of blepharospasm and when no other causes can be found. Suggestion techniques can be an indicator of a psychogenic cause.

2. Case History

A sixty five year old married woman presented with episodic inability to open her eyes after closure for the past 6 months. Each episode was abrupt in onset following watering and itchy sensation. In the initial 2 months, it occurred three times per day, each episode lasting for 10 minutes which gradually increased in frequency to 6 times per day lasting for 2 hours. In the past 4 months, she became home bound. She required help for routine activities. There was no history of other involuntary movements or focal neurological def i cits. Her thyroid status was stable with 50 micrograms of levothyroxine. She had undergone a hysterectomy 6 years earlier. There was no family history of any neurological or psychiatric disorder. Her general and neurological examination did not reveal any contributory findings. Routine blood examination, renal function tests, liver function tests, electrolytes, blood sugar, electrocardiography, computed tomography scan of the brain, electromyography were all within normal limits. She was diagnosed with essential blepharospasm and started on trihexyphenidyl 6 milligrams per day.But, there was no improvement even after 1 month of therapy. So, she was injected with 7 units of botulinum toxin only in the right eye lid. To our surprise, she got relief in both eyelids. But, on the evening of the same day, she started suffering from severe blepharospasm each lasting for 3 hours. Upon follow-up after 3 days,her psychosocial issues were discussed as she was referred to a specialty clinic of psychiatry. While giving her the next dose of botulinum toxin over the eyelid,she was given suggestions like “If you don’t open your eyes then your eyes with being closed for a whole prolonged period after this injection.” This time, she was injected with distilled water over her right eyelid instead of toxin, but she rapidly opened her eyes without any discomfort. She was again given a suggestion like “If this happens again in the house then we might have to give higher doses of injection which may lead to the permanent opening of eyes.” She was followed up after 1 week and found to be cured of the long lasting problem. Her psychosocial issues were recorded in the work up. There was a sudden role change in the family from a relaxed life to an overworked elderly woman.The patient described it as stressful as she was the only caregiver of the family and her sister in law had stopped working due to recently diagnosed epilepsy. Due to an overburdened life from morning to evening, she thought of going into hibernation by closing her eyes which eventually leaded to hospitalization and invasive treatments. She was found to have mild depressive symptoms. She was started on sertraline 25 milligrams.She was taught about different adaptive coping skills.Family therapy was initiated with all the members of her house. After 1 month, she was reviewed and found not to have any significant problem. She is under monthly follow-up in the department of psychiatry.

3. Discussion

Eyes are powerful ref l ectors of one’s emotional conflicts.According to Freud, eyes have a dual function as an organ of orientation and reception of pleasure stimuli.As for example “I cannot see” because “I do not want to see” ref l ects the unconscious defense mechanism to keep away conflict.[3]Psychogenic movement disorder is abrupt in its onset with high distractibility and selective disability. It is generally unilateral, a non-progressive course with inconsistent features and not present during sleep.[2,3]In our case, the presentation mimicked organic movement disorder as she presented with gradual onset bilaterally progressive course. The features were consistent and also present during sleep. The importance of giving suggestions has been described in the literature but often not practiced in Neurology.[4]Time constraints or instrumentalisation of modern neuroscience could be the factor contributing to the decreasing importance of suggestibility as an art. In our case, though the presentation was similar to an organic disorder but with the simple suggestion, she was relieved of her agonizing symptoms. Although botulinum toxin was injected in the fi rst occasion, the improvement was only short-lasting. We diagnosed the case as conversion disorder with psychological stressor, persistent type as per the diagnostic and statistical manual of mental disorders-5 (DSM 5). Culture related issues were taken care of as it was not a common cultural practice in the state of Kerala. We thought of other possibilities before concluding with the present diagnosis such as essential blepharospasm; thalamic, basal ganglia and cerebellar stroke but detailed neurological examinations did not reveal any other associated signs. The next entity we thought of was somatic symptom disorder as per DSM 5 but there were no significant feelings,thoughts or behavior related to the illness. Thepatient did not have any potential external gain, therefore it was not considered malingering. Moreover, there was no conscious intention. She did have a few symptoms of depression but did not meet criteria for clinical depression.

In this respect, our case shows the importance of lookingat the psychosocial issues and use of psychological treatments even in an organic presentation of movement disorders. It will avoid unnecessary investigations and invasive treatments.

Conflicting Interest

The authors declare that they have no conflict of interest related to this manuscript.

Funding

NIL

Informed consent

The patient signed an informed consent form and agreed to the publication of this case report.

Authors’ contributions

Das S, Sreedharan RP were in charge of concepts,design, definition, literature search, clinical studies,experimental studies, data acquisition, data analysis,statistical analysis, manuscript preparation, editing,and review. Remadevi PS was in charge of design,definition, literature search, manuscript preparation,editing, and review. Saji CV was in charge of concepts,definition, literature search, manuscript preparation,editing, and review. Finallys, Das S also took the responsibility as guarantor.

1. Hallett M. Blepharospasm: recent advances. Neurology.2002; 59: 1306–1312

2. Factor SA, Podskalny GD, Molho ES. Psychogenic movement disorders: frequency, clinical prof i le, and characteristics. J Neurol Neurosurg Psychiatry. 1995; 59(4): 406–412

3. Weller M, Wiedemann MP. Hysterical symptoms in ophthalmology. Doc Ophthalmol. 1989; 73(1): 1–33

4. Oakley DA, Halligan PW. Hypnotic suggestion: opportunities for cognitive neuroscience. Nat Rev Neurosci. 2013; 14(8):565–576. doi: http://dx.doi.org/10.1038/nrn3538

Dr. Soumitra Das obtained his Bachelor of Medicine degree in 2010 from Agartala Govt. medical College, Tripura, India and an MD in Psychiatry in 2015 from Govt. T D Medical College, Alappuzha,Kerala, India. He has started to work at the National Institute of Mental Health and Neuroscience,Bangalore, India since 2016, and now is currently working as a senior resident in the Department of Psychiatry. His research interests are ECT in clozapine resistant schizophrenia.

心理性眼睑痉挛：诊断的困境

Das S, Sreedharan RP, Remadevi PS, Saji CV

眼睑痉挛，心理性的，运动障碍，功能性障碍，印度

Blepharospasm is an uncontrolled spasmodic contraction of the orbicularis muscles of the eye resulting in an abnormal tic or twitch of eyes. It usually lasts for seconds to minutes but in severe cases eyes may be closed for hours. It may be essentially benign or secondary due to a lesion in basal ganglia,pyramidal tract, and trauma, local pathology in the eyes or drug induced. Here we are presenting a case of psychogenic blepharospasm. A 65 year old woman presented with a history of episodic inability of opening her eyes for the past 6 months. She had repeated abrupt closure of eyes which would persist for 1 hour. It made her socially and interpersonally disabled. Systemic and neurological causes were ruled out by detailed physical examinations and investigations including neuroimaging. Following poor response to oral medications she was injected with 7 units of Botox only in the muscles of the right eye. But within seconds she received relief in both eyes. During the next session she received a needle prick in one eye with no medication and immediately both of her eyes opened from a tightly closed position. In this case the patient reported stress due to increased workload around the house. From our case it depicts that a true movement disorder is often difficult to distinguish from functional disorder. So evaluation and management of patient’s external and internal stress will be of immense help before conducting any invasive treatment.

[Shanghai Arch Psychiatry. 2016; 28(6): 346-348.

http://dx.doi.org/10.11919/j.issn.1002-0829.216056]

1Department of Psychiatry, Goverment T. D. Medical College, Alappuzha, Kerala, India.

2Department of Neurology, Goverment General Hospital, Kottayam, Kerala,India.

3Department of Neurology, Goverment T. D. Medical College, Alappuzha, Kerala, India.

*correspondence: Dr.Soumitra Das. Mailing address: C/O: Makhan Lal Das, Panisagar, Dharmanagar, Tripura North, India. Postcode: 799260. E-Mail:soumitrstdmc@gmail.com

概述：眼睑痉挛是眼轮匝肌不受控制的痉挛性收缩导致眼睛异常抽动或抽搐。它通常持续几秒钟到几分钟，但在严重的情况下，眼睛可能会紧闭数小时。它可能是良性的，无论是原发的还是继发于基底节、锥体束的病变，眼部的创伤或局部病理情况引起的，或是药物所致的。在这里，我们报告一例心理性眼睑痉挛的病例。患者，女性，65岁，发作性无法睁眼6个月。她反复出现突然闭眼，往往要持续1 h。这使其无法人际交往，社会功能受损。详细的体检、包括神经影像学在内的检查排除了神经系统或其他系统性病因。口服药物治疗效果不佳，只在右侧眼睑肌射7个单位的肉毒素，几秒钟内，其双眼症状均得以缓解。之后一次治疗时，只用针刺一下一只眼睛，无需任何药物或暗示，患者就睁开紧闭的双眼。本病例中，患者曾报告过最近家务繁重感到有压力。这一病例表明，真正的运动障碍与功能性障碍鉴别往往有一定难度。因此，在进行任何有创治疗之前，评估患者的内外应激，并对此处理，将获益匪浅。