Successful Combination of Interventions for Psychogenic Blepharospasm— A Case Report

To the editor,

Conversion disorder (CD) is the presentation of abnormal motor or sensory symptoms sans organic causes. ¹ Psychogenic blepharospasm is a rare type of CD characterized by unintended twitching or contraction of the eyelids without structural origins. ² The prevalence is higher in developing countries like India (up to 31% in hospital settings). ³ Limited literature exists on interventions for psychogenic blepharospasm. This letter reports an amalgam of interventions used (Transcutaneous Electrical Nerve Stimulation [TENS, retraining movement], verbal suggestions, and aversion technique [pain/discomfort)]) to cause quick resolution of symptoms.

Case Description

A 12-year-old girl, studying in the sixth grade, hailing from Mauritius, came for psychiatric consultation for acute-onset bilateral blepharospasm. She claimed that upon waking one day, she was unable to open her left eye. Three months after this incident, her right eye also followed suit. The condition was continuous, lasting for eight months, accompanied by a mild headache. She used her fingers to keep her eyelids open for performing everyday tasks. No significant medical history or family history was elicited. She displayed la belle indifference. No emotional or behavioral concerns were brought forth. She went on to do her academic work as best as she could. She was examined by a neurologist, psychiatrist, and ophthalmologist in a hospital in India. Due to the presence of transient stiffness, transient tingling over the right-side extremities, and transient tremulousness in the right hand, differential diagnoses myasthenia gravis and autoimmune condition were suspected. She was put on a trial of intravenous immunoglobulin and started on pyridostigmine as empirical therapy. Because the condition began at the start of the pandemic, neurological manifestation of COVID was also suspected. Electromyography, Nerve Conduction Study, Repetitive Nerve Stimulation, HRCT-chest, MRI brain and orbit, and EEG ruled out various differential diagnoses. With this, pyridostigmine was discontinued. Psychological evaluation (Sentence Completion Test, Thematic Apperception Test, Rorschach Ink Blot Test, Millon Clinical Multiaxial Inventory) highlighted the intense need for affection and support from the immediate environment leading to underlying anxiety. A provisional diagnosis of CD (F44.4) was made. Ptosis crutches were prescribed and family counseling was suggested. She was brought to us as an outpatient by her mother through a referral from a friend. She was re-examined, and psychogenic origins were confirmed.

The treatment plan consisted of retraining the movement of eyelids (TENS) while diverting attention (trail-making tests) and providing suggestions. Previous literature claimed that TENS was effective in treating psychogenic movement disorders as it has neuro-modulatory effects. ⁴ On a predetermined date, she came to the lab for an initial meeting with the team of practitioners. She was first primed to believe that she had a genuine problem that could be undone using physiotherapy and psychotherapy. During her first (and only) session, she had to do a series of trail-making tests while her frontalis, corrugator supercilia, and orbicularis oculi muscles were electrically stimulated with minimal palpable muscle contraction. For each muscle, 30 contractions were given. During the stimulation and immediately after, her left eye had partially opened. The patient was informed that her eyes might open any time before the next session. The next day when she started wearing the eye crutches to do schoolwork, it was painful. This became an unintended aversion therapy. That night when she took off the crutches, she noticed that the lids stayed open. During her six-months and one-year follow-ups, no re-emergence was noticed.

Discussion

Some significant psychological stressor often precedes the onset of CD. ⁵ The patient and her mother were staying in Mauritius with her grandmother when the symptoms first emerged. One month before the onset of symptoms, her parents had separated due to the father’s drug consumption. They had moved in with her grandmother, who was then diagnosed with cancer. She has an easy and slow-to-warm-up temperament. Presenting the psychological explanation for her condition could have worsened her status. ⁶ Thus, treatment involved innocuous physiological intervention coupled with verbal suggestions.

The symptoms brought both primary and secondary gains, resulting in the sustenance of symptoms until treatment. ⁷ She benefitted from converting her emotional distress to physical symptoms as it moved the attention away from psychological conflicts (primary gain). She also received greater attention and care (secondary gain). According to the psychodynamic theory, unconscious drives such as dependency could present as CD. ⁸ The prolonged presentation could have been due to the reinforcing factors. In previous cases, verbal suggestions and Botulinum toxin therapy were used to induce a placebo effect and cause resolution of symptoms.^{9, 10} The efficiency of our proposed treatment method in comparison to existing methods requires further analysis. Future research can explore the universal effectiveness of the utilized treatment combination.

Consent

Written consent was obtained from the mother for the report.