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Artistic Clues to Psychogenic Tremor Using Pen and Paper
THE JOURNAL OF PEDIATRICS • www.jpeds.com
REDISCOVERING THE PHYSICAL EXAM
Artistic Clues to Psychogenic Tremor Using Pen and Paper
J
ust as graphologists surmise personality traits based on a person’s handwriting, clinicians should use the drawing of Archimedes spirals, lines, and written sentences to differentiate psychogenic from pathologic tremors. Although script patterns vary based on tremor type, Hess et al1 demonstrated that the Archimedes spiral was poorly reproducible in patients with psychogenic tremor. We propose that intact fine motor control in these patients creates script with high amplitude oscillations without compromising legibility. This fact is proven by the sample Archimedes spiral drawing and written sentence (Figure 1) of a 16-year-old girl who presented with tremor in the pediatric movement disorders clinic. She expressed all clinical characteristics of psychogenic tremor such as distractibility, variability, and entrainability. Diagnosis was confirmed by disappearance of tremor only on psychological counseling. This contrasts to patients with essential or other pathologic tremor whose lack of fine motor control leads to loss of legibility, even when the tremor is small in amplitude.2 This fact is also proven by the sample Archimedes spiral drawing and written sentence (Figure 2) of another 16-year-old girl with typical features of essential tremor who responded very well to primidone at a dose of 50 mg twice a day. Researchers have attempted to distinguish psychogenic from essential tremor using various clinical3 and electrophysiological4 parameters. We propose the simple method of drawing of Archimedes spirals, lines, and written sentences as a significant discriminating measure yet to be highlighted. ■
Figure 2. Despite the lower amplitude oscillations created on the Archimedes spiral and line drawing, note the poor quality of the drawing and also large and imprecise handwriting, seen in a patient with essential tremor. Black line without oscillations is drawn by the examiner.
Lauren James, MD Debabrata Ghosh, MD Nationwide Children’s Hospital Department of Neurology Ohio State University Medical Center Columbus, Ohio
References 1. Hess CW, Hsu AW, Yu Q, Ortega R, Pullman SL. Increased variability in spiral drawing in patients with functional (psychogenic) tremor. Hum Mov Sci 2014;38:15-22. 2. Nahab FB, Peckham E, Hallett M. Essential tremor, deceptively simple. . . Pract Neurol 2007;7:222-33. 3. Kenney C, Diamond A, Mejia N, Davidson A, Hunter C, Jankovic J. Distinguishing psychogenic and essential tremor. J Neurol Sci 2007;263:949. 4. Zeuner KE, Shoge RO, Goldstein JM, Hallett M. Accelerometry to distinguish psychogenic from essential or parkinsonian tremor. Neurology 2003;61:548-50.
Figure 1. Despite greater amplitude oscillations observed during the Archimedes spiral and line drawing, note the artistic pattern and clearly legible script seen in a writing sample from a patient with a psychogenic tremor. Black line without oscillations is drawn by the examiner. J Pediatr 2017;■■:■■ 0022-3476/$ - see front matter. © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2017.06.016
1 CRP 5.4.0 DTD ■ YMPD9270_proof ■ July 6, 2017
REDISCOVERING THE PHYSICAL EXAM
Artistic Clues to Psychogenic Tremor Using Pen and Paper
J
ust as graphologists surmise personality traits based on a person’s handwriting, clinicians should use the drawing of Archimedes spirals, lines, and written sentences to differentiate psychogenic from pathologic tremors. Although script patterns vary based on tremor type, Hess et al1 demonstrated that the Archimedes spiral was poorly reproducible in patients with psychogenic tremor. We propose that intact fine motor control in these patients creates script with high amplitude oscillations without compromising legibility. This fact is proven by the sample Archimedes spiral drawing and written sentence (Figure 1) of a 16-year-old girl who presented with tremor in the pediatric movement disorders clinic. She expressed all clinical characteristics of psychogenic tremor such as distractibility, variability, and entrainability. Diagnosis was confirmed by disappearance of tremor only on psychological counseling. This contrasts to patients with essential or other pathologic tremor whose lack of fine motor control leads to loss of legibility, even when the tremor is small in amplitude.2 This fact is also proven by the sample Archimedes spiral drawing and written sentence (Figure 2) of another 16-year-old girl with typical features of essential tremor who responded very well to primidone at a dose of 50 mg twice a day. Researchers have attempted to distinguish psychogenic from essential tremor using various clinical3 and electrophysiological4 parameters. We propose the simple method of drawing of Archimedes spirals, lines, and written sentences as a significant discriminating measure yet to be highlighted. ■
Figure 2. Despite the lower amplitude oscillations created on the Archimedes spiral and line drawing, note the poor quality of the drawing and also large and imprecise handwriting, seen in a patient with essential tremor. Black line without oscillations is drawn by the examiner.
Lauren James, MD Debabrata Ghosh, MD Nationwide Children’s Hospital Department of Neurology Ohio State University Medical Center Columbus, Ohio
References 1. Hess CW, Hsu AW, Yu Q, Ortega R, Pullman SL. Increased variability in spiral drawing in patients with functional (psychogenic) tremor. Hum Mov Sci 2014;38:15-22. 2. Nahab FB, Peckham E, Hallett M. Essential tremor, deceptively simple. . . Pract Neurol 2007;7:222-33. 3. Kenney C, Diamond A, Mejia N, Davidson A, Hunter C, Jankovic J. Distinguishing psychogenic and essential tremor. J Neurol Sci 2007;263:949. 4. Zeuner KE, Shoge RO, Goldstein JM, Hallett M. Accelerometry to distinguish psychogenic from essential or parkinsonian tremor. Neurology 2003;61:548-50.
Figure 1. Despite greater amplitude oscillations observed during the Archimedes spiral and line drawing, note the artistic pattern and clearly legible script seen in a writing sample from a patient with a psychogenic tremor. Black line without oscillations is drawn by the examiner. J Pediatr 2017;■■:■■ 0022-3476/$ - see front matter. © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2017.06.016
1 CRP 5.4.0 DTD ■ YMPD9270_proof ■ July 6, 2017