Introduction 

Cervical dystonia, also known as spasmodic torticollis, has long been a congenital or acquired condition among infants or young children. Its aetiology ranges from structural to neurological origins, but could it also be stress-related or psychologically driven?

Psychogenic (functional) torticollis is a rare condition characterised by involuntary, abnormal movements and postures of the head and neck. Unlike organic torticollis caused by structural or neurological abnormalities, psychogenic torticollis is considered a psychogenic (functional) movement disorder (PMD/FMD), typically triggered by emotional or psychological factors rather than physical ones.

Due to the intricate interplay between mind and body, psychogenic torticollis presents a notable diagnostic challenge. This condition is often underestimated by both neurologists and mental health professionals. This article offers an overview of its features and diagnostic criteria, aiming to help healthcare professionals distinguish it from organic torticollis and support accurate diagnosis and effective treatment planning.

Clinical features 

Sudden onset of abnormal head and neck posture 

The most typical signs of psychogenic torticollis are the abnormal tilting, twisting, or turning of the head and neck. In contrast to the gradual onset of organic cervical dystonia, the psychogenic form often develops rapidly following a psychological stressor or emotional trauma and may progress swiftly to severe disability, with near-complete or spontaneous remission.¹ 

Inconsistency and variability

Symptoms are typically inconsistent and fluctuate significantly. Involuntary movements such as neck twisting or head tilting vary in direction, intensity, and pattern over short periods. These movements differ from the consistent and stereotyped patterns seen in organic torticollis. Postural deviations and associated features, such as shoulder elevation and rotation, can also be notably dynamic. Unlike organic forms, sensory tricks (gestes antagonistes) are usually absent.^2,3 

Non-physiological or anatomical distribution  

Psychogenic torticollis often lacks a clear anatomical pattern. Movements may alternate between torticollis, laterocollis, or other postural types within minutes. Fixed dystonic postures at rest or erratic head tremors not typically observed in organic torticollis may also occur.³ 

Distractibility and suggestibility 

Symptoms often diminish or resolve when the patient is distracted (e.g., during conversation or examination), only to reappear when attention is refocused on the movement or during emotionally charged moments. This distractibility underscores the psychological origin and contrasts sharply with organic torticollis, where symptoms persist regardless of distraction.⁴ 

Disproportionate contractures and discomfort

Although severe pain, muscular hypertrophy, and permanent contractures are common in chronic organic torticollis, these physical signs are often minimal or absent in psychogenic torticollis, despite prominent involuntary movements.

Psychological stressors or comorbidities  

Psychogenic torticollis is frequently associated with significant psychological stress or psychiatric comorbidities. It may be a subconscious expression of unresolved emotional conflict, often linked to early trauma, adverse childhood experiences, depression, anxiety, or post-traumatic stress disorder (PTSD).^1,5 

Presence of other functional neurological symptoms 

The co-occurrence of other functional symptoms strengthens the psychogenic diagnosis. These may include:

• Functional limb weakness or tremors
• Psychogenic non-epileptic seizures
• Medically unexplained symptoms such as fibromyalgia, atypical chest pain, or irritable bowel syndrome¹  

Diagnosis 

Regarding the complexity of psychogenic torticollis, making an accurate diagnosis can be challenging as it requires extensive differentiation from other organic forms of torticollis. This is typically a comprehensive evaluation from various healthcare professionals, including neurologists, psychiatrists, and psychologists. 

Clinical history review 

The diagnostic process begins with a detailed medical history inquiry, including the onset and progression of involuntary neck movements and postures, triggering events, and a thorough review of past medical and psychiatric history, with a special investigation of any previous history of neck injuries or surgeries, as well as psychological stressors or traumatic events, for potential psychogenic origins. 

Physical (neurological) examination

A thorough neurological assessment is done to evaluate the absence of  “hard” neurological signs such as: 

• Cranial nerve dysfunction, typically that of cranial nerve XI, leading to difficulty with head-turning or shoulder-lifting 
• Spasticity or rigidity in neck muscles 
• Asymmetrical deep tendon reflexes (DTR)
• Clonus in the upper limbs 
• Gait or postural instability 
• Neurological dystonia or tremors 
• Sensory loss or pain 
• Weakness and atrophy of neck and shoulder muscles 

As well as observation of the involuntary movement patterns, scars from multiple operations or self-inflicted injuries, to preliminarily differentiate or rule out potential neurological contributing factors.¹ 

Ruling out organic causes 

Many diagnostic tests are needed to rule out any organic causes of movement and postural abnormalities, such as: 

• Imaging (X-ray, MRI, CT) scans of the brain, spinal cord, or cervical spine to detect lesions, such as:
  • Tumors 
  • Syringomyelia 
  • Chiari malformation
• Nerve conduction and electromyography (EMG) to assess for cervical nerves and muscle activities for neuromuscular disorders like myasthenia gravis or ALS
• Laboratory tests for metabolic or autoimmune disorders, such as thyroid dysfunction, lupus

Positive non-organic signs 

Diagnosing psychogenic torticollis typically involves the presence of non-organic (positive functional) signs, such as:

• The entrainment phenomenon, where abnormal neck movements are influenced or altered by rhythmic cues, such as tapping or movement synchronisation 
• Improvement of involuntary head or neck tilting when distracted or during a focused task 
• Paradoxical improvement of involuntary movements or posture during suggestion (e.g., asked to turn a fork) or simple manoeuvres of physical therapy or cognitive interventions 
• Associated with nonorganic signs, such as give-way weakness (by Hoover’s sign), non-anatomical sensory loss, resistance to passive movements, whole-body shaking, or excessive startle response
• Discrepancies either between the objective signs and disability, or between subjective reported symptoms and objective clinical test results. Examples:
  • Patients with mild unilateral weakness are bed- or wheelchair bound
  • Cases with no use of arms are capable of managing themselves at home on their own
  • Normal sensory evoked potentials in a case with total loss of sensation in a limb¹

Collaborative psychological and psychiatric assessment

Despite neurologists specialising in dystonia, multidisciplinary collaboration from both the psychological and psychiatric teams is crucial for an accurate diagnosis. Although many individuals have an entirely normal mental state, standardised tests and interviews with psychologists or psychiatrists could still be helpful to uncover any underlying psychological issues and potential emotional triggers that contribute to the development or persistence of involuntary neck movement.¹ 

Response to treatment 

Response to treatment can be valuable for diagnostic differentiation. While psychogenic torticollis may show improvement with psychotherapy, physical therapy, and even botulinum injection, but only shows limited effectiveness in organic torticollis. Longitudinal observation of treatment response can bring a clearer vision towards diagnostic differentiation. 

FAQs 

What are the symptoms of typical torticollis?

• Neck muscle pain that is potentially down the spine 
• Head tilting to one side 
• Inability to turn the head, by holding it twisted to one side 
• Spasm of neck muscles 
• Awkward chin position 

What is psychogenic (functional) movement disorder, and what are some other subtypes?

Psychogenic (functional) movement disorder (PMD/FMD) is a clinical syndrome of abnormal movements that are not explainable medically, with presumed psychogenic origin. Its subtypes include:

• Tremor and shaking 
• Dystonia and reflex sympathetic dystrophy 
• Myoclonus
• Parkinsonism 
• Tics
• Gait disorder
• Paroxysmal psychogenic movement disorders (dyskinesia)
• Psychogenic non-epileptic seizures 
• Functional paralysis and sensory disturbance ¹ 

What are some other characteristics of functional (psychogenic) movement disorder?

• Slurred speech, soft voice, gibberish, and foreign accent 
• Delayed and excessive startle 
• Active resistance against passive movement 

Summary 

Psychogenic torticollis is a functional movement disorder marked by involuntary neck movements with no identifiable neurological or structural cause. It frequently arises suddenly in response to psychological stress, displays inconsistent symptoms, and improves with distraction, traits not seen in organic torticollis.

Due to its diagnostic complexity and impact on quality of life, accurate diagnosis requires multidisciplinary collaboration. Early intervention and a holistic rehabilitation plan are key to improving outcomes and minimising long-term disability.