Skip Navigation
Skip to contents

JMD : Journal of Movement Disorders



Page Path
HOME > J Mov Disord > Volume 5(2); 2012 > Article
Case Report
Attention in Parkinson’s Disease Mimicking Suggestion in Psychogenic Movement Disorder
Jong Sam Baik
Journal of Movement Disorders 2012;5(2):53-54.
Published online: October 30, 2012

Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea

Corresponding author: Jong Sam Baik, MD, PhD, Parkinson Clinic, Department of Neurology, Sanggye Paik hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 139-707, Korea, Tel +82-2-950-1090, Fax +82-2-950-1955, E-mail
The author has no financial conflicts of interest.
• Received: September 2, 2012   • Revised: September 26, 2012   • Accepted: September 26, 2012

Copyright © 2012 The Korean Movement Disorder Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 59 Download
  • 3 Crossref
  • The various reported psychogenic movement disorders (PMDs) include tremor, dystonia, myoclonus, gait disorder, Parkinsonism, tics, and chorea. Although it is not easy to diagnose PMDs, several features such as distractibility, entrainment, suggestion and placebo trial are quite helpful to diagnose. Especially, distractibility or suggestion is a good tool to do in outpatient clinic easily. We describe a patient with parkinsonian features which were improved by internal suggestion to focusing attention. Initially, we suspected her diagnosis as PMDs; however she was confirmed with organic Parkinson’s disease later.
Despite drug therapy, gait disturbance remains a persistent characteristic motor deficit in Parkinson’s disease (PD). External cues, including auditory, visual, or somatosensory, have improved gait in patients with PD.1,2 However, executive dysfunction has also been related to gait difficulty in PD.3 Psychogenic movement disorders (PMDs) are not uncommon in neurological practice and have been reported with variable dyskinesia, including tremor, dystonia, myoclonus, gait disorder, chorea and Parkinsonism. Although the diagnosis of PMD is typically viewed as “diagnosis of exclusion”, some clues, including an abrupt onset, fluctuated symptom, underlying psychiatric comorbidity, or relieving by suggestion, can aid in the diagnosis of PMDs.
This 65-year-old woman had exhibited progressive gait disturbance over a one year period. For 15 years, her son had been in a vegetative state due to head trauma, and she had taken care of him. That had been a source of enormous stress for her. She was diagnosed with depression and had been taking antidepressants for five years. Last year, she felt that her legs dragged and were slow. These symptoms progressed slowly, despite intermittent fluctuation. When she presented in our clinic, she exhibited depressive mood; however, she denied any autonomic symptoms, including postural hypotension, urinary frequency, or constipation.
On neurological examination, she exhibited a mild masked face. Although the speed and amplitude of foot tapping were within normal limits, the amplitude of finger tapping decreased, additionally, speed slowed bilaterally. The motor power of her four extremities showed no weakness and there were no abnormalities on sensory examination. Deep tendon reflex was also normal. During walking, both of her feet dragged and were slowed with a bilateral decrease in arm swing. Sometimes, she hesitated to move exhibiting a glue feature while turning.
The findings of laboratory studies were unremarkable. A magnetic resonance imaging scan of her brain showed no abnormal findings. Interestingly, the patient reported that she could relieve her symptoms at will. When she concentrated hard on her gait or when she touched her hand to the posterior of her neck, her dragged and slow gait improved dramatically. Also, her abnormal gait improved when the examiner touched his hand to her neck (see video). Based on these curious conditions, we gave her placebo injections along with suggestion. However, there was no symptomatic change following this procedure. Subsequently, she was taken for an Fluoropropyl carbomethoxy-3b-(4-iodophenyltropane) ([18F]-FPCIT) positron emission tomography (PET) scan for evaluation of basal ganglia lesions. Results revealed a reduction in putaminal uptake bilaterally as compared to normal controls (Figure 1). She was then diagnosed with PD, levodopa treatment was initiated. After two months of levodopa treatment, her bradykinesia on both fingers had improved; however, her abnormal gait had not improved markedly. Informed, written consent was obtained after the patient had been given a complete description of the study using a video clip.
In this case, when the patient visited our clinic, she had some Parkinsonian symptoms, including masked face, bradykinesia on finger tapping, festinating gait, and glue-like turning. In spite of these common features in PD, the patient’s symptoms fluctuated and she had an underlying psychiatric comorbidity, such as anxiety and depression. Because these findings were common factors for diagnosing of PMDs, we suspected she had PMD. Otherwise, she had been able to relieve her abnormal gait at will or by touching her hand to the posterior neck. These unusual improving features can be found in PMDs rather than in organic disease.4 However, her symptoms did not change following placebo injection, although we found an improvement in her symptom through suggestion-like situations. These findings seemed reasonable in doubtful PMDs. A further, [18F]-FP-CIT PET scan was compatible with PD and furthermore, her symptoms improved after levodopa treatment.
Evidence from some clinical studies has supported the use of cues, including auditory, or somatosensory cues, to improve gait performance in PD.5,6 Executive functions, which has been defined as the ability to plan, manipulate information, initiate and terminate activities, and recognize errors,7 has been shown to play a major role in the gait of PD patient. Attention is an important part of executive function, and in our case, the patient was able to improve her symptoms by focusing her attention. That is, by focusing on gait or touching her hand to the posterior neck during walking, she was able to concentrate and thus, alleviate her symptoms. Furthermore, as with suggestion, her symptom improvement which occurred by touching our hand to her neck during walking caused us to misdiagnose her condition as a PMD, initially. Considering her [18F]-FP-CIT PET scan finding and her response of levodopa, we were able to diagnose her with PD rather than PMD. Although PMDs can mimic the full range of abnormal involuntary movement, including PD, this case made us confuse to diagnose an organic disease, initially, due to dramatic symptomatic improvement by only her attention. We emphasize the importance of attention for improving gait in patients with PD.
Segment 1. She had bradykinesia in both hands, which manifested itself in finger tapping which was slowed and fatigued. Bradykinesia was more severe in the hands than the feet.
Segment 2. During walking, she exhibited dragging and slowing gait with decreased arm swing. She also, hesitated to move during turning. These symptoms improved dramatically, when she touched her hand to the posterior of her neck or when the examiner touched his hand to her neck.
Figure 1.
Comparing to normal control (B), fluoropropyl carbomethoxy-3b-(4-iodophenyltropane) positron emission tomography scan of this patient (A) shows severely decreased uptake in the posterior portion of putamen bilaterally.
  • 1. Freeman JS, Cody FW, Schady W. The influence of external timing cues upon the rhythm of voluntary movements in Parkinson’s disease. J Neurol Neurosurg Psychiatry 1993;56:1078–1084.ArticlePubMedPMC
  • 2. Lewis GN, Byblow WD, Walt SE. Stride length regulation in Parkinson’s disease: the use of extrinsic, visual cues. Brain 2000;123(Pt 10):2077–2090.ArticlePubMed
  • 3. Cools R, Barker RA, Sahakian BJ, Robbins TW. Mechanisms of cognitive set flexibility in Parkinson’s disease. Brain 2001;124(Pt 12):2503–2512.ArticlePubMed
  • 4. Baik JS, Han SW, Park JH, Lee MS. Psychogenic paroxysmal dyskinesia: the role of placebo in the diagnosis and management. Mov Disord 2009;24:1244–1245.ArticlePubMed
  • 5. Morris ME, Iansek R, Matyas TA, Summers JJ. Stride length regulation in Parkinson’s disease. Normalization strategies and underlying mechanisms. Brain 1996;119(Pt 2):551–568.ArticlePubMed
  • 6. Nieuwboer A, Kwakkel G, Rochester L, Jones D, van Wegen E, Willems AM, et al. Cueing training in the home improves gait-related mobility in Parkinson’s disease: the RESCUE trial. J Neurol Neurosurg Psychiatry 2007;78:134–140.ArticlePubMedPMC
  • 7. Goverover Y. Categorization, deductive reasoning, and self-awareness: association with everyday competence in persons with acute brain injury. J Clin Exp Neuropsychol 2004;26:737–749.ArticlePubMed

Figure & Data



    Citations to this article as recorded by  
    • Functional neurological disorder and placebo and nocebo effects: shared mechanisms
      Mirta Fiorio, Miriam Braga, Angela Marotta, Bernardo Villa-Sánchez, Mark J. Edwards, Michele Tinazzi, Diletta Barbiani
      Nature Reviews Neurology.2022; 18(10): 624.     CrossRef
    • Functional Motor Symptoms in Parkinson’s Disease and Functional Parkinsonism: A Systematic Review
      Marine Ambar Akkaoui, Pierre A. Geoffroy, Emmanuel Roze, Bertrand Degos, Béatrice Garcin
      The Journal of Neuropsychiatry and Clinical Neurosciences.2020; 32(1): 4.     CrossRef
    • Somatization in Parkinson's Disease: A systematic review
      Danilo Carrozzino, Per Bech, Chiara Patierno, Marco Onofrj, Bo Mohr Morberg, Astrid Thomas, Laura Bonanni, Mario Fulcheri
      Progress in Neuro-Psychopharmacology and Biological Psychiatry.2017; 78: 18.     CrossRef

    Comments on this article

    Add a comment
    Related articles

    JMD : Journal of Movement Disorders Twitter