Journal of
Original communications
J Ne urol (1991)238 : 140-146
Ho w to ide ntify ps ychoge nic dis orde rs o f s tance and gait
A vide o s tudy in 37 patie nts
T. Le mpe rt*, T. Brandt, M. Die te rich, and D. Huppe rt
Ne urologis che Unive rs itfits klinik, KlinikumGros s ha de rn,Ma rchioninis tra s s e15, W-8000 Mtinche n,Fe de ra lRe public of Ge rma ny
Re ce ive dMa y 23, 1990/ Re ce ive din re vis e d form S e pte mbe r15, 1990/ Acce pte dOctobe r22, 1990
S ummary. Th irty-s e ve n p a tie n ts with p s yc h o g e n icd is o r-
d e rs o f s ta n c e a n d g a it we re clinica lly e va lu a te d ,re c o rd e d
o n vid e o , a n d a n a lys e d with re g a rd to c lin ic a l p h e n o -
m e n o lo g y. C h a ra c te ris tic , s u g g e s tive a n d u n s p e c ific fe a -
tu re s we re id e n tifie d . S ix c h a ra c te ris tic fe a tu re s p ro ve d
m o s t va lu a b le fo r d ia g n o s is o f p s yc h o g e n e s is a, s th e y o c -
c u rre d a lo n e o r in c o m b in a tio n in 9 7 % o f p a tie n ts : (1)
m o m e n t a r y flu c tu a tio n s o f s ta n c e a n d g a it, o fte n in re -
s p o n s e to s u g g e s tio n ; (2) e xc e s s ive s lo wn e s s o r h e s ita -
tio n o f lo c o m o tio n in c o m p a tib le with n e u ro lo g ic a l dis -
e a s e ; (3) "p s yc h o g e n ic "R o m b e r g te s t with a b u ild -u p o f
s wa y a m p litu d e s a fte r a s ile n t la te n c y o r with im p ro ve -
m e n t b y d is tra c tio n ; (4) u n e c o n o m icp o s tu re s with wa s t-
a g e o f m u s c u la r e n e rg y; (5) th e "wa lkin g o n ic e " g a it
p a tte rn , wh ic h is c h a ra c te riz e d b y s m a ll c a u tio u s s te p s
with fixe d a n kle jo in ts ; (6) s u d d e n b u c klin g o f th e kn e e s ,
u s u a lly with o u t fa lls . S e ve n ty-th re e p e rc e n t o f p a tie n ts
h a d a d d itio n a l s u g g e s tive fe a tu re s . C la s s ific a tio n in to
c h a ra c te ris tic s u b typ e s wa s n o t fo u n d u s e fu l b e c a u s e
p r e d o m in a n t fe a tu re s va rie d fro m p a tie n t to p a tie n t a n d
o c c u rre d in va rio u s c o m b in a tio n s . F a c titio u s im p a irm e n t
o f s ta n c e a n d g a it wa s s tu d ie d in 13 h e a lth y d ra m a s tu -
d e n ts . S im u la te d g a it d ys fu n c tio n a p p e a re dle s s c o n s p ic u -
o u s a n d m o r e d iffic u lt to d ia g n o s e th a n th e c lin ic a l p s y-
c h o g e n ic d is o rd e rs .
Ke y words : Hys te ria - C o n ve rs io n - G a it
Introduction
P s yc h o g e n icd is o rd e rs a re n o t u n c o m m o n in n e u ro lo g i-
c a l s e ttin g s . Th e y we re th e p rim a ry c a u s e o f a d m is s io nin
9 % o f 4470 n e u ro lo g ic a l in p a tie n ts o f th e Mu n ic h Un i-
ve rs ity C lin ic b e twe e n 1985 a n d 1987 [10]. P s yc h o g e n ic
d ys fu n c tio n o f s ta n c e a n d ga it wa s o b s e rve din 68 p a tie n ts .
* P re s e n t addre s s a n d addre s s fo r o ffp rin t re que s ts ': Ne urologis che
Abte ilung, Unive rs it~its -Klinikum Rudolf Virchow, S pa nda ue r
Da mm 130, W-1000 Be rlin19, Fe de ra l Re publicof Ge rma ny
Neurology
© S pringe r-Ve rla g1991
Th e s e 1 .5 % c o m e c lo s e to th e p ro p o rtio n o f p a rkin s o n ia n
p a tie n ts (2 .2 % ) in th e s a m e s e rie s o f c o n s e c u tivep a tie n ts .
In c lin ic a l p ra c tic e , d ia g n o s is re lie s m a in ly o n th e o b s e r-
va tio n o f b iz a rre m o t o r b e h a vio u r, d is c re p a n c yb e twe e n
o b vio u s d ys fu n c tio n a n d n o rm a l d ia g n o s tic e va lu a tio n ,
a n d e vid e n c e o f p s yc h ia tric a b n o rm a litie s . S o m e c a s e s
re m a in o b s c u re d e s p ite c a re fu l in ve s tig a tio n s a n d a re
c la rifie d o n ly o n fo llo w-u p .
Th e im p o rta n c e a n d fre q u e n c y o f p s yc h o g e n icd is o r-
d e rs o f s ta n c e a n d g a it a re n o t re fle c te d in th e re c e n t lit-
e ra tu re o r te xtb o o ks . F o r g e n e ra l d e s c rip tio n s , n e u ro -
lo g is ts h a ve to s e a rc h th ro u g h o ld te xtb o o ks [1, 2, 7, 15].
With th e e xc e p tio n o f Ke a n e ' s s u rve y o f 60 c a s e s [8], a u -
th o rs h a ve re c e n tly re p o rte d o n ly s in g le c a s e s [13, 17,
18]. S ys te m a tics tu d ie s a re s till la c kin g .
We h a ve trie d to e s ta b lis h d ia g n o s tic c rite ria fo r p s y-
c h o g e n ic d is o rd e rs o f s ta n c e a n d g a it b y a n a lys in g a s e rie s
o f vid e o -d o c u m e n te dc a s e sa s p re vio u s a u th o rs h a ve d o n e
fo r p s yc h o g e n ics e iz u re s [3, 5, 6, 11]. Th e p o in t in q u e s -
tio n wa s wh e th e r d ia g n o s is is p o s s ib le o n p h e n o m e n o -
lo g ic a l g ro u n d s a lo n e a n d wh e th e r a n a n a lys is o f s in g le
fe a tu re s o r a c la s s ific a tio n in to c h a ra c te ris tics u b typ e s is
m o re p ra c tic a l fo r d ia g n o s is . It wa s n o t o u r in te n tio n to
a n a lys e th e a e tio lo g y a n d p a th o p h ys io lo g yo f th e s e dis -
o rd e rs b u t to d e fin e p h e n o m e n o lo g ic a lc lu e s fo r d ia g -
n o s is .
Patie nts and me thods
Be twe e n J a nua ry1988a nd Ma rch 1989, we pros pe ctive ly s tudie d
22 pa tie ntswith ps ychoge nic dys functionof s ta ncea nd ga it. Afte r
informe d cons e ntha d be e nobta ine d,e a chpa tie ntwa s vide o-ta pe d
for 5-10min a ccording to a s ta nda rdize dprogra mmewhich in-
clude d s ta nding, wa lking with e ye s ope na nd clos e d,ta nde mwa lk-
ing, wa lking on toe s a nd he e ls , a fullkne e be nda nd Rombe rgte s t-
ing. We re tros pe ctive ly a na lys e d15 a dditiona l ca s e sdocume nte d
be twe e n 1980 a nd 1984 which fulfille d compa ra blete chnica l a nd
dia gnos tic s ta nda rdsThe. vide o of e a ch pa tie nt wa s re vie we d a nd
a na lys e d s e ve ra l timeby
s all a uthors . Dia gnos is waba s s e d onun-
us ua l phe nome na ,incons is te ncie sa nd contra dictions which we re
incompa tible with ne urologica l dis e a sEa e . ch pa tie nt ha d a n a de -

qua te dia gnos tic work-up to e xclude a n unde rlying orga nic dis -
e a s e .In a boutha lf of the ca s e sdia gnos iswas confirme d by a ra pid
re s pons e to s ugge s tivethe ra py which include d e ncoura ge me nt,
phys iothe ra pya nd pla ce bome dica tion.
Re s ults
Patie nts
Th e s tu d y c o m p ris e s37 p a tie n ts b e twe e n 19 a n d 78 ye a rs
o f a g e (m e a n 46 ye a rs ). P a tie n ts we re e ve n ly d is trib u te d
a m o n g a ll a g e g ro u p s . Twe n ty-two (6 2 % ) we re fe m a le ,
15 (3 8 % ) m a le .
Ge ne ralfe ature s
In 27 p a tie n ts (7 3 % ), th e p s yc h o g e n icn a tu re o f th e dis -
tu rb a n c e wa s s u g g e s te db y its b iz a rre , n o n -n e u ro lo g ic a l
a p p e a ra n c e .In 10 p a tie n ts (2 7 % ), th e d is o rd e re d wa lk
re s e m b le dm o re o r le s s a n o rg a n ic n e u ro lo g ic a ld is e a s e ,
s u c h a s P a rkin s o n 's s yn d ro m e (4 c a s e s ),n o rm a l-p re s s u re
h yd ro c e p h a lu s (2 ), p o lyn e u ro p a th y (2 ), p a re s e s o f th e
q u a d ric e p sm u s c le (1) a n d s c ia tic a (1).
Th e s e ve rity o f ga it d ys fu n c tio n wa s a s s e s s e da c c o rd -
in g to th e fu n c tio n a l a n d s o c ia l im p a irm e n t it c a u s e d .
E ig h te e n c a s e s (4 9 % ) we re ra te d a s "s e ve re ". Th e s e p a -
tie n ts we re e ith e r c o m p le te lyu n a b le to s ta n d o r wa lk o r
a c c o m p lis h e do n ly a fe w s te p s . C o m m o n s e q u e la ewe re
u s e o f th e wh e e lc h a ir, te m p o ra ryo r p e rm a n e n td is a b ility
a n d re tre a t fro m s o c ia l a c tivite s . F ifte e n c a s e swe re cla s -
s ifie d a s "m o d e ra te ", wh ic h m e a n t m a rke d ga it d ys fu n c -
tio n with fa irly we ll p re s e rve dm o b ility. F o u r c a s e s(1 0 % )
we re ra te d a s "s lig h t". Th e s e p a tie n ts h a d u n o b tru s ive
g a it a b n o rm a litie s wh ic h c a u s e d o n ly n e g lig ib le fu n c -
tio n a l im p a irm e n t.
P s yc h o g e n icg a it d is tu rb a n c ewa s c o m b in e d with n e u -
ro lo g ic a l g a it d ys fu n c tio n in 1 p a tie n t wh o h a d m ild c o n -
g e n ita l te tra s p a s tic itya n d flu c tu a tin g p s yc h o g e n ica s ta s ia .
F o u r p a tie n ts h a d n e u ro lo g ic a l d is o rd e rs wh ic h d id n o t
a ffe c t s ta n d in g a n d wa lkin g .
Characte ris tic fe ature s
R e vie win g o u r p a tie n ts we id e n tifie d clinica l fe a tu re s o f
p s yc h o g e n icg a it d is o rd e rs a n d c la s s ifie d th e m in to two
c a te g o rie s : c h a ra c te ris tic a n d s u g g e s tive . C h a ra c te ris tic
s ym p to m s a re lis te d with th e ir re s p e c tive fre q u e n c y in
Ta b le 1 a n d a re d e lin e a te din th e fo llo win g .
Fluctuations o f ga it a n d s ta n c e o f p e rfo rm a n c ein c o m -
p a tib le with n e u ro lo g ic a l d is e a s e o c c u rre d in m o re th a n
h a lf o f o u r p a tie n ts with in th e 5 -1 0 ra in o f e va lu a tio n .
R e p e a te d e xa m in a tio n s o n s e ve ra l o c c a s io n s in c re a s e d
th e yie ld . F lu c tu a tio n s e ith e r a p p e a re ds p o n ta n e o u s lyo r
c o u ld b e p ro vo ke d b y th e p h ys ic ia n . E n c o u ra g e m e n t
a n d d is tra c tio n b y c e rta in ta s ks s u c h a s fin g e r-n o s e te s t-
ing m ig h t im p ro ve th e d is tu rb a n c e c o n s id e ra b ly. S o m e -
tim e s ga it re tu rn e d to n o rm a l wh e n wa lkin g wa s re n d e re d
m o re d iffic u lt, e .g . in wa lkin g o n tip to e .
F lu c tu a tio n s a ls o m a y o c c u r in n e u ro lo g ic a l d is e a s e
s u c h a s m ya s th e n ia g ra vis , d ys ka la e m ic p a ra lys is a n d
e xtra p yra m id a ld is o rd e rs . Mo m e n ta ry to -a n d -fro flu c tu -
141
Ta ble 1. Cha ra cte ris tic fe a ture s of ps ychoge nicdys function of
s ta ncea nd ga it in 37 pa tie nts
n
Fluctua tion of impa irme nt 19
Exce s s ives lowne s sof move me nts 13
He s ita tion 6
"P s ychoge nicRombe rg"te s t 12
"Wa lking on ice " ga it pa tte rn 11
Une conomicpos ture swith wa s teof mus clee ne rgy 11
S udde nbuckling
without fa lls 8 10
with fa lls 2
As ta s ia 4
Ve rtica l s ha kingtre mor 3
a tio n s , h o we ve r, a re in d ic a tive o f a p s yc h o g e n ico rig in
(Fig. 1).
E xc e s s ive s lowne s s o f m o ve m e n ts re s e m b lin g s low-
m o tio n wa s s e e n in 13 p a tie n ts . Us u a lly, it is b ro u g h t
a b o u t b y s im u lta n e o u sin n e rva tio n o f a n ta g o n is tm u s c le s
wh ic h m a y re fle c t th e c o n flic t b e twe e n vo lu n ta ry in te n -
tio n a n d s u b c o n s c io u sre s tra in t. S lo w ga its d u e to n e u ro -
lo g ic a l d is e a s em a y re s u lt fro m d e c re a s e ds trid e le n g th a s
in P a rkin s o n 's s yn d ro m e o r fro m e xte n d e d in te r-s trid e
in te rva ls to c o m p e n s a tefo r p o s tu ra lin s ta b ility a s in a ta xia
o r p a re s is . In c re a s eo f m u s c le to n e m a y d e c e le ra tem o ve -
m e n ts to a c e rta in d e g re e ,b u t e xc e s s ives lo win g d o e s n o t
o c c u r. O rth o p a e d ic p a tie n ts m a y wa lk s lo wly to a vo id
m o ve m e n t-in d u c e dp a in . No n e o f o u r "p s yc h o g e n ic "p a -
tie n ts , h o we ve r, c o m p la in e d o f p a in .
A re la te d p h e n o m e n o nlike wis e c a u s e d b y c o -in n e r-
va tio n o f a n ta g o n is t m u s c le s is he s itation, wh ic h o c c u r-
re d in 6 c a s e s . In th e s e p a tie n ts in itia tio n o f in te n d e d
m o ve m e n tis e ith e r d e la ye d o r im p o s s ib le . S m a ll fo rwa rd
a n d b a c kwa rd m o ve m e n ts o f th e le g m a y b e o b s e rve d
wh ile th e fe e t s e e m to s tic k o n th e g ro u n d . In c o n tra s t to
P a rkin s o n 's s yn d ro m e th e in h ib itio n is n o t o ve rc o m e
o n c e th e firs t s te p is d o n e b u t re c u rs with e ve ry s te p .
R o m b e rg te s ting wa s p e rfo rm e d in 25 p a tie n ts , 12 o f
wh o m s h o we d o n e o r m o re fe a tu re s o f a "p s yc h o g e n ic "
R o m b e rg te s t:
1. C o n s ta n t fa lls to wa rd s (3 p a tie n ts ) o r a wa y fro m (4
p a tie n ts ) th e o b s e rve r, irre s p e c tive o f his p o s itio n . F a lls
a re u s u a lly a vo id e d b y c lu tc h in g th e p h ys ic ia n .
2. La rg e a m p litu d e b o d y s wa y, b u ild in g u p a fte r a s ile n t
la te n c y o f a fe w s e c o n d s .
3. Im p ro ve m e n t o f p o s tu ra l b a la n c e wh e n th e p a tie n ts
a re d is tra c te d , e .g . b y a s kin g th e m to re c o g n iz en u m b e rs
writte n b y fin g e r o n th e ir s kin o r b y o th e r m a n o e u vre s
(Fig. 2).
"W alking on ice " - a c h a ra c te ris ticg a it p a tte rn u s e d b y
n o rm a l p e o p le o n s lip p e ry g ro u n d s - wa s s e e nc o n s ta n tly
in 11 p a tie n ts . It c o n s is ts o f c a u tio u s , u s u a lly b ro a d -
b a s e d s te p s with d e c re a s e ds trid e le n g th a n d h e ig h t, s tif-
fe n in g o f kn e e s a n d a n kle s , s o m e d e g re e o f a n ta g o n is t
in n e rva tio n a n d (in s o m e p a tie n ts ) s h u fflin g o f th e fe e t
Fig. 1. F lu c tu a tin g ga it d is tu rb a n c e
with wa s te o f m u s c u la r e n e rg y: p a tie n t
s ta rts wa lkin g u p rig h t, th e n g o e s s lowly
into a full kn e e b e n d a nd b e c o m e se re c t
a ga in o n h e r wa y ba ck
Fig. 2. P s yc h o g e n icins ta bility o f s ta n c e
with "n o n -n e u ro lo g ic a l"s tiff le a n in g
to th e s ide , wh ic h s tops with d is tra c tio n
by fin g e r-n o s e te s tin g
Fig. 3. "'Wa lking on ic e ": h e s ita n t, s low
ga it with a n xio u s b a la n c in g , s tiff kn e e s
a nd a nkle s , a nd re d u c e d s te p h e ig h t a nd
s tride le n g th

(Fig. 3). Th e g a it a b n o rm a lity o f p a tie n ts with n o rm a l-
p re s s u re h yd ro c e p h a lu ss h a re s s o m e o f th e s e fe a tu re s ,
b u t la c ks th e a n xio u s b a la n c in gu s u a lly with a b d u c tio no f
th e a rm s wh ic h c h a ra c te riz e sth e s e p a tie n ts .
In 11 p a tie n ts u n e c o n o m icp o s tu re swith was teo f m us -
cle e ne rgy in o rd e r to m a in ta in b a la n c ewe re n o te d . E xa m -
ple s a re a s s u m p tio na n d m a in te n a n c eo f p o s tu re swith a n
e c c e n tric d is p la c e m e n to f th e c e n tre o f g ra vity, s ta n d in g
a n d wa lkin g with fle xio n o f hips a n d kn e e s (Fig. 1) a n d
s lo win g o r a rre s tin g a kn e e b e n d h a lf-wa y d o wn .
R e p e a te ds u d d e n buckling o f the kne e s o c c u rre d in 10
p a tie n ts with (2) a n d with o u t (8) fa lls . P a tie n ts u s u a lly
p re ve n te d th e m s e lve s fro m fa llin g b y a c tiva tin g th e ir
a n ti-g ra vity m u s c le s b e fo re th e y to u c h e d th e g ro u n d ,
wh ic h re q u ire d a c o n s id e ra b le e xp e n d itu re o f s tre n g th
(Fig. 4). E ve n if fa lls o c c u r, th e y a re m o re o r le s s di-
re c te d to a vo id s e lf-in ju ry, wh ic h m a ke s th e m e a s ily dis -
tin g u is h a b le fro m d ro p a tta c ks . S u d d e n kn e e fle xio n s
h a ve b e e n o b s e rve din Hu n tin g to n 's c h o re a [9], b u t m a y
b e d is tin g u is h e db y a c c o m p a n yin gc h o re a ticm o ve m e n ts .
In c a ta p le xy,los s o f m u s c le to n e a p p e a rso n ly in re s p o n s e
to s u d d e n e m o tio n a ls tim u li.
F o u r p a tie n ts p re s e n te dwith as tas ia, wh ic h is a ps y-
c h o g e n icin a b ility to s ta n dwith o u t s u p p o rt with p re s e rve d
fu n c tio n o f th e lo we r lim b s in th e re c u m b e n t p o s itio n .
Th re e p a tie n ts h a d vig o ro u s up a n d d o w n s h a k in g o f the
b o d y wh ic h wa s g e n e ra te db y ra p id ly a lte rn a tin g fle xio n
a n d e xte n s io no f th e kn e e s a n d - to a le s s e rd e g re e - o f
hips a n d a n kle s . Arm s we re e ith e r n o t in vo lve d o r m o ve d
p a s s ive ly,wh ic h h e lp s to d is tin g u is h this typ e o f tre m o r
fro m o rg a n ic va ria n ts . Bo d y tre m o r fre q u e n c ywa s in th e
ra n g e o f 3 -6 Hz in o u r p a tie n ts , wh ic h c o n tra s tswith th e
fa s te r o s c illa tio n s o f o rg a n ic o rth o s ta tic tre m o r [12].
Th irty-s ix p a tie n ts (9 7 % ) s h o we d o n e o r m o re o f th e
s ix m o s t c o m m o n c h a ra c te ris tic fe a tu re s : flu c tu a tio n s ,
s low m o tio n a n d h e s ita tio n , "p s yc h o g e n ic ",R o m b e rg
te s t, "wa lkin g o n ic e ", s u d d e n b u c klin g a n d wa s te o f
m u s c le e n e rg y. F o u rte e np a tie n ts (3 7 % ) a n d o n ly o n e o f
Ta ble 2. S ugge s tivefe a ture sof ps ychoge nicdys functionof s ta nce
a nd ga it in 37 pa tie nts
Motors ym ptom s(n = 22)
P s e udota xia
of the le gs
of the trunk
S udde ns ide s te ps
Fla iling of the a rms
Dra ggingof the le g
Continuousfle xion of the toe s
Continuouse xte ns ionof the toe s
Biza rre tre mors (ha nds7, le gs3, trunk 2, he a d1)
Expressivebehaviour(n = 19)
Gra s pingthe leg 6
Ma nne re dpos tureof ha nds 6 P s yc h o g e n icd is o rd e rs in h o s p ita l p a tie n ts a re u s u a lly re -
S uffe ringor s tra ine dfa cia le xpre s s s ion 15
Moa ning 8
Hype rve ntila tion 3
143
th e s e s igns , 10 (2 7 % ) h a d two , 5 (1 4 % ) a n d th re e , 4
(1 1 % ) h a d fo u r a n d 3 (8 % ) h a d five . Th e o n ly p a tie n t
wh o h a d n o n e o f th e s e fe a tu re s wa s a wo m a n with p s e u -
d o m yo c lo n u so f th e rig h t le g wh ic h re c u rre d a b o u t e ve ry
10 s . S u d d e no n s e t with a s e rie s o f p s yc h o g e n ics e iz u re s ,
a b iz a rre tre m o r o f th e rig h t h a n d a n d s p o n ta n e o u sre -
m is s io n with in 2 d a ys c o n firm e d th e d ia g n o s isin this pa -
tie n t.
S ugge s tivefe ature s
Ad d itio n a l s igns s u g g e s tin ga p s yc h o g e n icd is o rd e r oc-
c u rre d in 73% o f o u r p a tie n ts (Ta b le 2). We c a lle d th e m
s u g g e s tive ,s ince d iffe re n tia tio n fro m n e u ro lo g ic a l d ys -
fu n c tio n wa s s o m e tim e sn o t a s o b vio u s a s in th e c h a ra c -
te ris tic fe a tu re s d e s c rib e da b o ve .
P s e u d o a ta xiare fe rs to a n in s ta b ility o f p o s tu re a n d
g a it wh ic h is c h a ra c te riz e db y d e m o n s tra tive b a la n c in g
s o m e tim e s with fla iling o f th e a rm s a n d b iz a rre e xc u r-
s ions o f th e tru n k wh ile le gs a re o fte n u n a ffe c te d(Fig. 5).
P a tie n ts m a y p e rfo rm s u d d e n s id e s te p so r tu m b le a b o u t.
Th e b ro a d -b a s e dg a it o f n e u ro lo g ic a la ta xia is ra re .
In p s yc h o g e n icm o n o p a re s is ,th e a ffe c te d le g is o fte n
d ra g g e db e h in d a n d m a y b e b iz a rre ly twis te d , u s u a lly in
a n e q u in o va ru s p o s itio n . Te m p o ra ry in n e rva tio n o f th e
p a ra lys e dle g m a y b e o b s e rve d (Fig. 6).
C o n tin u o u s fle xio n o r e xte n s io n o f th e to e s m a y b e
s e e n in p a tie n ts with o th e rwis e n o rm a l m u s c le to n e .
P s yc h o g e n ictre m o rs c a n o fte n b e id e n tifie d b y th e ir
u n u s u a l d is trib u tio n , c o n c o m ita n t b iz a rre p o s tu rin g o f
e xtre m itie s a n d a lle via tio n b y d is tra c tio n . In c o n tra s t to
o rg a n ic tre m o rs th e ir fre q u e n c y m a y va ry c o n s id e ra b ly
in a n in d ivid u a l p a tie n t. Th e d is ta l p o rtio n s o f th e lims
m a y b e s p a re d a n d m o ve lim p ly in re s p o n s eto p ro xim a l
m u s c le a ctivity. In th e a b s e n c e o f th e s e fe a tu re s , h o w-
e ve r, p h e n o m e n o lo g ic a ld iffe re n tia tio n m a y p ro ve dif-
ficult.
F ifty-o n e p e rc e n t o f p a tie n ts d is p la ye d e xp re s s ive o r
d e m o n s tra tive b e h a vio u r (Fig. 7) wh ic h m a y, h o we ve r,
o c c u r like wis e in n e u ro lo g ic a lp a tie n ts with c o n c o m ita n t
p s yc h ic a b n o rm a litie s .
Clas s ification into s ubtype s
It wa s o u r clinica l im p re s s io nth a t p s yc h o g e n icd is o rd e rs
o f s ta n c e a n d g a it m a y b e c la s s ifie din to s u b typ e sa c c o rd -
in g to p re d o m in a n tfe a tu re s .Th e s im ila rity o f m a n ife s ta -
tio n s wa s s trikin g in s o m e p a tie n ts ; th e o ve ra ll va ria b il-
ity, h o we ve r, wa s s o la rg e th a t th e clinica l u s e o f th is a p-
p ro a c h p ro ve d im p ra c tic a l. F o u r s u b typ e sc o m p ris in g 14
p a tie n ts (3 8 % ) c o u ld b e fo rm e d , wh e re a s th e o th e r 23
p a tie n ts d e m o n s tra te din d ivid u a l m a n ife s ta tio n so r h a d
va rio u s c o m b in a tio n s (Ta b le 3).
Factitious gait dis orde rs
g a rd e d a s th e re s u lt o f s u b c o n s c io u sconflicts . F o r c o m -
p a ris o n we s tu d ie d a p h e n o m e n o lo g yo f vo litio n a lly fa ke d
ga it d is o rd e rs in 13 h e a lth y d ra m a s tu d e n ts . Th e y we re
a s ke d to s im u la te a g a it d is o rd e r wh ic h s h o u ld b e s e ve re
144

Fig. 4. P s ychoge nicbuckling, P a tie ntfa lls

forwa rd with s udde nfle xion of hips a nd
kne e s a nd re ma insin a n une conomic
ha lf-fle xe d pos ture
Fig. 5. P s ychoge nicps e udoa ta xicins ta bil-
ity of s ta ncea nd ga it with wobblingof the
trunk, biza rre ba la ncinga nd fla iling of
the a rms , which ce a s e s withdis tra ction
Fig. 6 a -c . P s ychoge nicmonopa re s isof
the right le g. a Dra ggingof the twis te d
le g, gra s pingthe le g; b "pa ra lys e d"right
le g s upports thebody during s wing pha s e
of the le ft le g; c inne rva tionof the "pa ra -
lys e d" le g a fte r e ncoura ge me nt

Fig.7. P s ychomotor s ymptoms
of ps ychoge nic ga it dis orde rs :
s uffe ring fa cia l e xpre s s ion
a nd
gra s pingof the le g
Table 3. Cla s s ifica tionof ps ychoge nic dys function of s ta nce a nd in 20 p a tie n ts . In c o n s is te n c yo ve r tim e a n din c o n g ru ity
ga it into cha ra cte ris tic s ubtype(37 s pa tie nts )
Slowga it 6 (16%) Othe rtype s 12a (31%)
As ta s ia 3 (8%)
P s e udota xia 3 (8%) Combina tions 11 (30%)
Buckling 2 (6%)
a Include s : ps e udomyoclonus , rhythmica l s ide -to-s ide rocking,Th e s e fe a tu re sin c lu d e u n u s u a lp o s tu re sa n d ga it p a tte rn s ,
fixe d fle xion of hips a nd kne e s , ge ne ra lize d tre mor, "wa lking on a s trikin g s lowne s s o f lo c o m o tio n a s we ll a s m o m e n ta ry
ice ", tripping propuls ion with fa lls , he s ita tion, monopa re s is with
dra ggingof the le g, unila te ra l limp, bila te ra l e quinova rus pos ture
of the fe e t, wa ddling in a s qua tting pos ition, dra gging a long (like tio n is o f p a rtic u la r va lu e . In a s m a ll p ro p o rtio n o f p a -
a n e xha us te d wa nde re r in the de s e rt)
e n o u g h to c o n vin c e th e p h ys ic ia n o f a d is e a s e c a u s in g th e n ia gra vis , d ys ka la e m icp a ra lys is ,e a rly p o lyra d ic u litis
d is a b le m e n t.E a c h s tu d e n tre c e ive d a writte n in s tru c tio n
2 d a ys b e fo re e va lu a tio n . Vid e o -ta p e s we re re c o rd e d
a n d a n a lys e da s d e s c rib e d a b o ve . Th e s m a ll n u m b e r o f
in ve s tig a te ds u b je c ts d o e s n o t a llo w a d e ta ile d c o m p a ri- p o s tu ra l in s ta b ility, re d u c e d s te p h e ig h t a n d c o -c o n tra -
s on, b u t s o m e re m a rka b led iffe re n c e swe re n o te d b e twe e n
p a tie n ts a n d vo lu n te e rs . In c o n tra s t to o u r p a tie n ts th e
m a jo rity o f a c to rs (n = 8) s h o we d d is o rd e rs with a ra th e r
"o rg a n ic " a p p e a ra n c e Five
. o f th e a ctors h a d m o n o p a re s is
o f o n e le g a n d 3 h a d lim p in g with o u t re le va n t p a re s is a s
th e ir p re d o m in a n t fe a tu re . F lu c tu a tio n s o c c u rre d in 5
s u b je c ts ,e xce s s ive s lowne sin s 2, wa s te o f m u s c le e n e rg y
in 2, a n d b u c klin g in o n e , wh e re a s o th e r s pe cific s ym p -
to m s s u c h a s h e s ita tio n , "p s yc h o g e n ic " R o m b e rg te s t
a n d th e "wa lkin g o n ic e " p a tte rn we re n o t o b s e rve d .F ive
s u b je c ts s h o we d n o n e o f th e s pe cific s ym p to m s ; o n ly 5
h a d a d d itio n a l s u g g e s tive s ym p to m s a s c o m a p re d with
73% in th e p a tie n t g ro u p . Th e a ve ra g en u m b e r o f s pe cif-
ic a n d s u g g e s tives igns p e r s u b je c t wa s 1.5 in s im u la te d
a n d 4.3 in clinica l d is o rd e rs .
In s u m m a ry, s im u la te d g a it d is o rd e rs a p p e a re d le s s
c o n s p ic u o u s a n d m o re d iffic u lt to d ia g n o s e b yp h e n o -
m e n o lo g y a lo n e th a n clinica l p s yc h o g e n ic g a it d is tu r-
b a n c e s . Ne ve rth e le s s ,th e re wa s a c o n s id e ra b leo ve rla p
b e twe e n th e two , wh ic h m a ke s clinica l d is tin c tio n dif-
ficult in in d ivid u a l ca s e s .
145
Dis c us s io n
P s yc h o g e n icd is o rd e rs o f s ta n c e a n d g a it h a ve a ttra c te d
little s c ie n tific a tte n tio n s o fa r in s pite o f th e ir fre q u e n t
o c c u rre n c e in n e u ro lo g ic a l p ra c tic e . In a re tro s p e c tive
s u rve y o f 60 ca s e s ,32 o f wh ic h we re d o c u m e n te do n m o -
tio n p ic tu re o r vid e o , Ke a n e [8] fo u n d 24 p a tie n ts with
h e m ip a re s is o r p a ra p a re s is ,23 with a ta xia a n d 9 with
tre m b lin g , wh e re a so th e r typ e s o f "h ys te ric a l"ga its we re
ra re . His d e s c rip tio n o f th e clinica l p h e n o m e n o lo g ycor-
re s p o n d s we ll to o u r fin d in g s . Th e fre q u e n c yo f s pe cific
p s yc h o g e n icm o to r p a tte rn s , h o we ve r,wa s n o t re p o rte d .
Ke a n e e m p h a s iz e d th a at fe w m in u te s o fg a it e xa m in a -
tio n u s u a lly le a d to th e c o rre c t d ia g n o s is .Th o m p s o na n d
S ills [17] p re s e n te d9 p a e d ia tric ca s e so f p s yc h o g e n icg a it
d ys fu n c tio n . Dia g n o s is wa s b a s e d o n d is c re p a n c ie s o f
s ym p to m s ,s igns a n d fu n c tio n , a s we ll a s o n p s yc h o s o c ia l
c o n c o m ita n ts ,wh e re a ss pe cific p h e n o m e n o lo g ic acl rite ria
we re n o t a p p lie d . F a h n a n d Willia m s [4] re p o rte d 21
ca s e so f p s yc h o g e n icd ys to n iawh ic h s ta rte d in th e fo o t in
10 p a tie n ts a n d fin a lly in vo lve d o n e o r b o th lo we r lim b s
with cla s s ica ld ys to n ia wa s o b s e rve d in 18 p a tie n ts . E x-
ce s s ive s lo wn e s s o f m o ve m e n to c c u rre d in 5 ca s e s . G a it
a b n o rm a litie swe re n o t a n a lys e din d e ta il.
In o u r s tu d y we id e n tifie d s ix c h a ra c te ris tic c rite ria
wh ic h a llo w a p h e n o m e n o lo g ic a dl ia g n o s is in o ve r 90%
o f ca s e s with s u ffic ie n t c e rta in ty a t th e firs t e va lu a tio n .
flu c tu a tio n s . Th e m o d ifie d R o m b e rg te s t with d is tra c -
tie n ts (< 1 0 % ) d ia g n o s is is d iffic u lt. In o u r e xp e rie n c e ,
d iffe re n tia tio n m a y b y e s p e c ia lly in tric a te fro m s o m e
fo rm s o f m yo c lo n u s ,e xtra p yra m id a lh yp e rkin e s ia ,m ya s -
a n d , la s t b u t n o t le a s t, n o rm a l-p re s s u reh yd ro c e p h a lu s .
Th e g a it d is o rd e r o f n o rm a l-p re s s u reh yd ro c e p h a lu sis
c h a ra c te riz e d b y s h o rt s trid e le n g th , s low s p e e d a n d
c tio n o f a n ta g o n is tm u s c le s[14, 16], th u s m im ic kin gs o m e
o f th e a b o ve -d e s c rib e fe d a tu re s o fp s yc h o g e n icg a it dys -
fu n c tio n .
P h e n o m e n o lo g ic adia
l gnos isis s u p p o rte db y a d d itio n a l
d ia g n o s tic clue s . Th e h is to ry m a y re ve a l e m o tio n a lc o n -
flicts , a m o d e l fo r th e s ym p to mo r p re vio u s s o m a tiz a tio n s .
P h ys ic a l e xa m in a tio n m a y s h o w d is c re p a n c ie s s u c ha s
n o rm a l re fle xe s in a c h ro n ic a lly p a ra lys e d le g o r give -
wa y we a kn e s s .It s h o u ld b e n o te d , h o we ve r, th a t obvi-
o u s o rg a n ic a lte ra tio n s s u c h a s m u s c le a tro p h y o r jo in t
c o n tra c tu re s d o n o t n e c e s s a rilya rg u e a g a in s t a p s yc h o -
ge nic d is o rd e r, a s th e y m a y re p re s e n ts e c o n d a ryc h a n g e s .
P s yc h ia tricc o n s u lta tio nis a d vis a b le to re ve a l o c c u ltps y-
c h o p a th o lo g y.F in a lly, e lim in a tio n o f s ym p to m s b y s ug-
g e s tio n , p la c e b o o r p s yc h o th e ra p ym a y s e rve a s a n ulti-
m a te c o n firm a tio n o f th e d ia g n o s is .
In c o n c lu s io n ,we a d vo c a teth e p h e n o m e n o lo g ic a al p-
p ro a c h to p s yc h o g e n ic d ys fu n c tio n o f s ta n c e a n d g a it,
s ince it is d ire c t, e ffe c tive , a n d a vo id s u n n e c e s s a ry,cos tly
a n d p o te n tia lly h a rm fu l d ia g n o s tic p ro c e d u re s .
146
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