Case Report - (2015) Volume 0, Issue 0
Department of Psychiatry, LGB regional Institute of Mental Health, Tezpur, Assam, India
Patients with psychogenic torticollis are generally among the most difficult to treat psychiatry patients, as psychological factors play a major role. 3% of the torticollis patients presenting to neurology Outpatient department reveals non organic etiological basis. Pharmacotherapeutics and psychological approaches both are used to treat these cases. But success rate of complete cure is minimal. Habbit reversal technique has not been generally applied to treat these cases. Here we are reporting a case of psychogenic torticollis who was treated with application of this technique.
Psychogenic torticollis, Psychotherapy, Habbit reversal technique.
“Dystonia is a movement disorder which is characterized by sustained muscle contractions, along with twisting and repetitive movements or abnormal postures. Dystonia may be part of many disorders with a variety of causes. Dystonia can be classified by age of onset, distribution of symptoms, or by etiology”. [1-3] “The term torticollis is derived from the Latin words tortus for twisted and collum for neck”. [4] Congenital and acquired are the two major types of torticollis.[4] Various causes of torticollis are mainly birth trauma, tuberculosis of the spine, posterior fossa tumour, infections in the posterior pharyngeal wall and infected adenoids etc. [1,3,4] Among the drugs antipsychotics phenothiazines are seen to be associated with transient torticollis.[5] Literatures have shown that approximately 3% of the patients attending a neurology unit reveals non organic basis of torticollis.[5] Psychological disturbances are found to be associated with the onset of these group of patients.[5] Relaxation exercise, antispasmodics and benzodiazepines have been used while treating a case of psychogenic torticollis. [6] “Habbit reversal training is a type of behavior therapy which has been used primarily in treating tic disorder, trichotillomania, nail bitting, skin pricking and thumb sucking etc”. [7] It comprises of maily four stages like: Awareness training, competing response training, contingency management, relaxation training and generalization training.[7] However the use of habbit reversal technique has not been demonstrated in cases of psychogenic torticollis till yet. Here we have tried to demonstrate the use of this technique in a case of torticollis, which was associated with psychological disturbance.
Case History
A 27 years hindu male, who was a diagnosed case of schizophrenia, attended our outpatient department (OPD) with bending of the neck to one side from 3 months. Observation of his medical record revealed that he presented to our OPD 4 months back with chief complaint of fearfulness, suspiciousness and disorganized behavior. After detailed examination he was diagnosed to be a case of schizophrenia and tablet Risperidone 6 mg/day and trihexiphenidyl 2mg were advised to him. After some days of receiving risperidone patient complained that he had sudden spasmodic contraction of the neck muscle. He was thought to be sufferering from drug induced acute dystonia and injection promthazine was given instantly. He got immediate relief on receiving promethazine. Tablet Trihexiphenidyl was titrated `upto 4 mg. The patient has done well for some days after that. But on a regular follow up, he again complained of having similar type of bending of the neck towards one side. Injection Promethazine was again injected instantly. But this time patient did not get any relief. The peculiarity of this presentation was that the patient was able to keep his neck straight on suggestion and bending was not associated with pain. The Sternocleido mastoid muscle was not also felt to be contracted. On detailed enquiry patient`s mother revealed that he was very much stressed about their financial issues. Examination of the ear and pharynx did not reveal any abnormality. The patient denied having any history of undergoing surgical procedures. Apart from antipsychotics patient did not have any history of receiving any other drug. Cervical X-ray and MRI were performed to rule out any vertebral disc abnormality.Looking at the whole scenario and the association of the stress with the onset and maintenance of the illness led us to arrive at a diagnosis of psychogenic torticollis. During his subsequent visits he was advised various suggestions like exercise, manual stretching, medications like muscle relaxants, Baclofen and Anticholinergics. But no improvement was noted. Patient was planned for Habbit reversal training. At first awareness was provided regarding his problem. He was taught to do a movement opposite to the bending of the neck whenever the premonitory urge comes. After repeated training and simultaneous relaxation exercise a significant improvement had been noted. Picture 1 has shown the patient.
Figure 1: picture showing examination of the patient.
Various psychological factors like depression, anxiety, phobia, avoidant personality disorder are associated with the onset of the psychological torticollitis as reported by Feinstein et al. [8] However, in our case we failed to identify any major similar psychological issues. Our patient was already a diagnosed case of schizophrenia and risperidone induced acute dystonic reaction acted as a precipitating factor. While psychological issues like financial issues and burden of harboring schizophrenia played a role as a maintaining factor. Relaxation exercise, benzodiazepines and antispasmodics are preferred as a treatment in case of torticolis. Radonja et al. had described a similar case of torticolis which was precipitated by psychological disturbance.[5] They managed the patients with pharmacological treatment and psychological intervention. [5] We also attempted conventional management while treating our case. But all these interventions failed to give significant improvement. Habit reversal training is generally used in Tic disorder, nail biting, Trichotillomania and thumb sucking. No literature has reported the use of Habbit reversal training in cases of Torticollis till yet. Motivation behind our reporting is to highlight the use of this specialize form of behavioral therapy as an alternative option of treatment in case of psychogenic torticollis. Apart from the behavioral therapy other psychological interventions should also be simultaneously administered to eliminate the etiology of the disturbance.
Authors will be interested to hear similar cases from others.
Diagnosis and management of a case of psychogenic torticollis is difficult, due to interplay of psychological issues. Management strategies should give emphasis on both behavior therapy and resolution of psychological conflict.
There are no conflicts of interest
NIL
