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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 39 OF 100
A 31-year-old man presents with abnormal arm movements that began a few weeks ago following a rear-end collision in which he was the restrained driver. Airbags did not deploy in either car, and the patient does not believe he injured his head or neck. The morning after the collision, he noticed his arms started shaking and continued to shake all day and have done so consistently since onset. Examination reveals a variable-frequency tremor in both hands that seems to change in quality depending on his position. The movements cease with distraction, such as when examining his legs, and seem to be more severe whenever the movements are discussed. A functional movement disorder is suspected. What is the most appropriate step in the approach to this case?
A. MRI of the brain to exclude structural injury
B. Formal neuropsychological evaluation **
C. Serum copper and ceruloplasmin levels
D. Video assisted electroencephalogram (vEEG)
E. No additional studies are needed.
** = Your answer
Functional or psychogenic movement disorders can occur in patients with preexisting psychiatric conditions, may develop following sudden trauma, or may occur without any apparent triggers. When a functional disorder is suspected, examination findings such as entrainment, distractibility, and suggestibility can be strongly suggestive of the diagnosis. A movement disorder often is characterized by unusual and/or nonphysiologic features that are not expected with an organic disorder. When these features are seen, especially when a clear trigger is present, no other diagnostic workup is necessary. Initial discussion with the physician about the underlying disorder may be sufficient to treat the symptoms, although some patients require additional psychiatric or psychological treatment.
* Louis E. Diagnosis and management of tremor. Continuum Lifelong Learning Neurol. 2016;22(4):1143-1158.