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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 161-163

Functional movement disorders during the COVID-19 pandemic

1 Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
2 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India

Date of Submission23-May-2021
Date of Decision06-Jul-2021
Date of Acceptance27-Aug-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Pramod Kumar Pal
Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru - 560 029, Karnataka.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AOMD.AOMD_26_21

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Functional movement disorders (FMDs) are a heterogenous group of movement abnormalities that greatly affect the quality of life of patients. They usually manifest as a result of underlying psychological or psychiatric illnesses without any known structural or neurochemical diseases. Various neurological disorders such as encephalitis, stroke, demyelination, seizures, and neuropathy have been reported by otherwise healthy individuals during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Here, we describe the case of a 27-year-old woman who presented to our outpatient department with episodes of deviation of angle of mouth with variability and distractibility. Following thorough clinical evaluation and appropriate investigation, the underlying etiology was identified as FMD secondary to the restrictions imposed during the COVID-19 pandemic to contain the transmission of the virus. The lockdown, isolation, financial strain, and other pandemic-related issues are stressors that may contribute to psychogenic disorders in people.

Keywords: COVID-19, facial dystonia, functional movement disorders, lockdown, pandemic

How to cite this article:
Kamath SD, Kamble N, D M S, Sakhardande KA, Basavarajappa C, Pal PK. Functional movement disorders during the COVID-19 pandemic. Ann Mov Disord 2021;4:161-3

How to cite this URL:
Kamath SD, Kamble N, D M S, Sakhardande KA, Basavarajappa C, Pal PK. Functional movement disorders during the COVID-19 pandemic. Ann Mov Disord [serial online] 2021 [cited 2023 May 31];4:161-3. Available from: https://www.aomd.in/text.asp?2021/4/3/161/333361

  Introduction Top

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 has had a major impact on healthcare systems and patients globally. Functional movement disorders (FMDs) are a heterogenous group of disorders commonly presented due to psychological or psychiatric stressors rather than neurologic disturbances.[1],[2] FMDs can range from hyperkinetic movements such as dystonia, tremors, myoclonus, chorea, abnormal facial movements, and tics to hypokinetic movements such as  Parkinsonism More Details, stiff person syndrome, and gait disorder.

Although COVID-19 clinically presents as a respiratory disease, its neurological manifestations have been reported in many patients.[3] While several of these cases are being postulated as secondary to the infection, the psychosocial impact of the measures taken to decrease community transmission of the virus cannot be ignored. Prevention and control measures such as isolation of COVID-19-positive individuals, home and hospital quarantine, contact tracing, and country-wide extended periods of lockdown have already been noted to have a negative impact on mental health.[4] Here, we explore the impact of the pandemic and lockdown on an individual who developed FMD as a result. Written informed consent was obtained from the patient and ethical waiver was obtained from the Institutional Ethics Committee (No. NIMH/DO/DEAN (Basic Science)/2020-21).

  Case Report Top

A 27-year-old woman with no previous comorbidities presented with a history of repeated episodes of deviation of angle of mouth towards the right side for 1 month. Each episode was abrupt in onset, lasting for half an hour to 1 hour. She experienced no associated behavioral arrest, loss of consciousness, weakness, or sensory symptoms in any other part of the body. During these episodes, the patient could speak coherently but her speech was slightly slow with mild stuttering. She could chew food without spillage and swallow without coughing, choking, or nasal regurgitation. These episodes occurred four to five times/day. There was no history of neuroleptic use or past history of behavioral or neurological symptoms. The patient’s nephew had a history of seizures and was undergoing treatment. His seizures were frequently witnessed by the patient, and she experienced facial deviation followed by tonic-clonic movements of the limbs and loss of consciousness after a few months. The patient or her family had no history of prior psychiatric illness. During examination, she experienced an episode just as she was entering our outpatient consultation room; hence, she was speaking slowly. On observation, she was conscious, oriented, and her vitals and general physical examination was normal. The angle of her mouth was deviated to the right with partial normalization on attempting to speak consonants rapidly. Only the lower half of her face was involved. Furthermore, the patient was asked to raise her eyebrows, close her eyes tightly, and blow her cheeks which resulted in complete normalization of the deviation, suggesting variability and distractibility [Video-segment 1]. In addition, there was slight head tilt to left side and mild rotation of the head to right side. Her other neurological examination was normal. A working diagnosis of functional hemifacial spasm (HFS) was made. The patient was reassured and prescribed multivitamins. Further testing revealed microcytic anaemia, but her serum electrolytes, renal, and liver function tests were normal. Brain magnetic resonance imaging (MRI) results were normal with no evidence of neurovascular conflict involving the facial nerve. Electroencephalography was normal. Moreover, we learned that due to the COVID-19 pandemic-related lockdown, the patient and her husband had recently experienced severe financial crisis and were facing possible eviction from their home, as they were unable to pay the house rent. Psychiatric opinion was sought and she was diagnosed with mixed anxiety–depressive disorder. She was started on escitalopram and tapering doses of clonazepam, in addition to counselling. She underwent regular follow-up with multiple behavioral therapy sessions over the next 2 months. On the first day of consultation during her follow-up, her symptoms had almost completely improved, with no recurrence of the episodes. Her neurological examination was normal, with normal speech and no deviation of angle of mouth [Video-segment 2]. At the time of submission of this case report, her financial crisis had resolved after the lockdown restrictions were eased.

  Discussion Top

Several people have faced financial crises due to strict lockdown rules implemented worldwide. This coupled with the anxiety of contracting COVID-19 and the health implications of the same has led to an increased number of individuals seeking psychosocial support.[4],[5] Since mid-March 2020, the Government of India has imposed nationwide mass quarantine with phased relaxation of the restrictions occurring even at the time of drafting this report. Several Indian citizens have sought help for anxiety, suicidal ideations, depression, and other behavioral disturbances during this period.[4] Our report reveals that the development of psychiatric disturbances can be indirect, such as in the form of FMD, following a challenging event threatening emotional and financial security.

If approached systematically, it is possible to detect FMDs in the neurology outpatient department.[6],[7] The patient’s thorough history considering the paroxysms, stressors and contributing factors, detailed examination, and features of variability and distractibility strengthened our diagnosis. Improvement in her symptoms after reassurances and psychological therapy points towards a functional etiology. We conducted necessary investigations to eliminate disorders that closely mimicked her symptoms. However, normal MRI did not exclude HFS and functional HFS. Once the diagnosis was established, we understood that to successfully manage FMD, we had to use an empathetic approach.[8] The misconceptions regarding COVID-19 and its related restrictions were noted as the underlying cause of aggravating the condition of our other patients with neurological diseases such as Parkinson’s disease.[9] Similar misconceptions were identified and addressed during our patient’s behavioral therapies, which were eliminated through an empathetic approach. Numerous psychological sequelae such as stress, depression, irritability, insomnia, confusion, and anger have been observed in quarantined individuals and healthcare providers.[10]

Pandemics and epidemics have been known to affect psychosocial integrity and cause psychosocial maladjustment. People tend to be susceptible to cognitive, behavioral, and emotional alterations.[11] Social isolation has been proved to provoke increased stress levels, anxiety, fear and irritability, emotional instability, and inability to make coherent decisions.[12] These factors may precipitate FMDs in vulnerable individuals. A recent study reported increased incidence of FMDs in children and adults during the current COVID-19 pandemic, possibly due to increased psychological stress.[13],[14]

The effects of social isolation due to lockdown can be traumatic. The significance of our case is that psychiatric symptoms resembling neurological ones are exhibited by patients who before the lockdown had no neurological or psychological incidents. Insufficient food supply, financial losses, unemployment, and difficulty in accessing healthcare facilities can precipitate psychological problems, sometimes manifesting as physical disabilities. These factors should be considered during therapeutic management.

Author contributions

Sneha Dayanand Kamath, Nitish Kamble and Sindhu DM contributed in acquisition and interpretation of data and in writing first draft of the manuscript. Kasturi A. Sakhardande, Chethan Basavarajappa and Pramod Kumar Pal contributed in interpretation of data and in review and critique of the manuscript.

Ethical compliance statement

Ethical approval for this study was waived by the institute ethics committee owing to the retrospective nature of the study (No. NIMH/DO/DEAN (Basic Science)/2020-21). Written informed consent of the patient was obtained for the video recording and for online publication and dissemination.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest to declare.

  References Top

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Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science. Lancet Psychiatr 2020;7:547-60.  Back to cited text no. 5
Hallett M. Functional (psychogenic) movement disorders - Clinical presentations. Parkinsonism Relat Disord 2016;22:S149-152.  Back to cited text no. 6
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Prasad S, Holla VV, Neeraja K, Surisetti BK, Kamble N, Yadav R, et al. Parkinson’s disease and COVID-19: Perceptions and implications in patients and caregivers. Mov Disord 2020;35:912-4.  Back to cited text no. 9
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.  Back to cited text no. 10
Serafim PA, Gonçalves PD, Rocca CC, Neto FL. The impact of COVID-19 on Brazilian mental health through vicarious traumatization. Braz J Psychiatry 2020;42:450.  Back to cited text no. 11
Zhang J, Wu W, Zhao X, Zhang W. Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: A model of West China Hospital. Precis Clin Med 2020;3:3-8.  Back to cited text no. 12
Hull M, Parnes M, Jankovic J. Increased incidence of functional (psychogenic) movement disorders in children and adults amidst the COVID-19 pandemic: A cross-sectional study. Neurol Clin Pract 2021. doi: 10.1212/CJP.0000000000001082.  Back to cited text no. 13
Piscitelli D, Perin C, Tremolizzo L, Peroni F, Cerri CG, Cornaggia CM. Functional movement disorders in a patient with COVID-19. Neurol Sci 2020;41:2343-4.  Back to cited text no. 14


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