Repetitive transcranial magnetic stimulation plus standardized suggestion of benefit for functional movement disorders: an open label case series.
BACKGROUND
We studied suggestion of benefit combined with motor cortex and premotor cortex repetitive transcranial magnetic stimulation (rTMS) in chronic (>2 years) FMDs.


METHODS
Patients were identified from our patient records who had clinically definite FMDs and had undergone neuropsychiatric evaluation. Those with chronic FMDs were offered open-label rTMS over the dominant motor cortex. If they failed to improve they received dominant premotor cortex rTMS. The primary outcome was change from baseline to post-rTMS in quality of life measured by the World Health Organization Quality of Life Brief (WHOQOL-BREF) scale. Secondary outcomes were subject and investigator global impression of change (GIC), blinded Rush psychogenic movements rating scale, Barbers suggestibility scale, baseline expectation of benefit scale, and adverse effects.


RESULTS
Six subjects were enrolled. For the primary outcome, there was significant improvement in the physical domain scores but significant reduction in psychological domain scores after premotor cortex rTMS compared to baseline and after motor cortex rTMS. There was no significant change between baseline and motor cortex rTMS or in any other domain after premotor cortex rTMS. Secondary outcome measures showed no meaningful change. Transient headache and worsening of FMD symptoms were the most common adverse effects observed.


CONCLUSIONS
rTMS combined with strong suggestion of benefit provided dissonant results after premotor cortex rTMS with improvement in physical quality of life but reduction in psychological quality of life. These results serve to underscore the complex nature of FMDs where the overt physical manifestation is but one part of a comprehensive neuropsychological syndrome.
University of Virginia Department of Neurology, Charlottesville, VA, USA. Electronic address: binitshah@virginia.edu.
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Shah
Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada; The Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Ontario, Canada.
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Chen
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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Zurowski
Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada; The Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Ontario, Canada.
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Kalia
Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada; The Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Ontario, Canada.
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Gunraj
Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada; The Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Ontario, Canada.
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Lang
D000328:Adult; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009044:Motor Cortex / Q000503:physiopathology*; D009069:Movement Disorders / Q000523:psychology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D010865:Pilot Projects; D011788:Quality of Life; D013001:Somatoform Disorders / Q000523:psychology / Q000628:therapy*; D013404:Suggestion; D050781:Transcranial Magnetic Stimulation / Q000379:methods*
Functional movement disorders; Psychogenic; Psychogenic movement disorders; Repetitive transcranial magnetic stimulation; Suggestion