Australian & New Zealand Journal of Psychiatry 1 © The Royal Australian and New Zealand College of Psychiatrists 2018 Article reuse guidelines: sagepub.com/journals-permissions journals.sagepub.com/home/anp Australian & New Zealand Journal of Psychiatry, 00(0) A case of psychogenic Parkinsonism: Late age of onset should not be a barrier to make the diagnosis Rohith Kumar 1 and Rajeev Kumar 2,3,4,5 1 St George’s Hospital, University of London, London, UK 2 Academic Unit of Psychiatry and Addiction Medicine and College of Medicine, Biology, and Environment, ANU Medical School, Canberra, ACT, Australia 3 Consultation-Liaison Psychiatry Unit, The Canberra Hospital, Canberra, ACT, Australia 4 Neuropsychiatry Clinics, Canberra, ACT, Australia 5 Psychiatry Department, Hamad Medical Corporation, Doha, Qatar Corresponding author: Rajeev Kumar, Consultation-Liaison Psychiatry Unit, The Canberra Hospital, Building 4, Level 2, Canberra, ACT 2606, Australia. Email: rajeevkumar@me.com DOI: 10.1177/0004867418804068 To the Editor Psychogenic (functional) Parkinsonism (PP) is an uncommon form of func- tional movement disorder with a prev- alence of 1.5% of all patients referred for Parkinsonism (Sage and Mark, 2015). Published literature till date showed that the typical mean age range of patients with PP is 37–53 years. A 76-year-old man was referred for a psychiatric assessment for a suspected PP by his geriatrician, as he had non- progressive Parkinson’s disease (PD) along with non-response to dopaminer- gic medications in the context of poor coping at home and concerns raised by his daughter. He presented with bilat- eral upper and lower limb tremor with an unsteady gait and slowness of movements. He was diagnosed PD 6 years ago by a neurologist. Sudden onset of restless legs, tremor, bradykin- esia and gait abnormality characterized his earlier symptoms, leading to a diag- nosis of PD. He received carbidopa and levodopa for 5 years with no benefit, but interestingly, with no deterioration of symptoms typically seen in PD. There was no history suggestive of depression, anxiety or cognitive impairment. He had an unusual blend of rest, postural and action tremor of both upper and lower limbs. His tremor varied in intensity and frequency during examination using various distraction techniques. At times, he hyperventilated and appeared taking considerable effort to complete a motor task. There was no cogwheel rigidity. His gait was ataxic with typical astasia–abasia. A previous magnetic res- onance imaging (MRI) brain revealed an old, small size incidental meningioma, not requiring any intervention. The diagnosis of PP was made on clinical characteristics and absence of a clinical course typically seen in patients with PD (Koukouni and Bhatia, 2007). The major challenge of this case was to make a definitive diagnosis of PP because he has previously been diagnosed and treated with PD and had a much later age of onset. However, the characteris- tic nature of the unusual combination of neurological symptoms and the varia- tion in intensity and frequency with dis- traction suggested that it was unlikely to be due to PD (Bhatia and Schneider, 2007). Although the presence of psy- chological factors is helpful in making the diagnosis, clinical experience is that either this is not present or not availa- ble at the time of assessment in about 50% of patients. Careful and detailed examination of the abnormal move- ments and demonstrating the inconsist- ency are key aspects of making a correct diagnosis of PP and late onset should not be a barrier to diagnose PP. Table 1 shows some of the clinical indicators of making a diagnosis of PP. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Funding The author(s) received no financial sup- port for the research, authorship and/or publication of this article. References Bhatia KP and Schneider SA (2007) Psychogenic tremor and related disorders. Journal of Neurology 254: 569–574. Koukouni V and Bhatia KP (2007) Psychogenic Parkinsonism. In: Koller KC and Melamed E (eds) Handbook of Clinical Neurology, vol. 84. New York: Elsevier, pp. 501–506. Sage JI and Mark MH (2015) Psychogenic Parkinsonism: Clinical spectrum and diagnosis. Annals of Clinical Psychiatry 27: 33–38. Letter 804068ANP ANZJP CorrespondenceANZJP Correspondence Letter Table 1. Clinical pointers suggesting a diagnosis of Psychogenic Parkinsonism. 1. Acute onset of symptoms with the absence of a typical course or deterioration seen in Parkinson’s disease. 2. Unusual or bizarre combination of tremor and various gait abnormalities, especially the presence of astasia–abasia. 3. Variability in the intensity and frequency of abnormal movements using distraction techniques. 4. Excessive fatigue and labored attempt to complete motor tasks. 5. Deliberate slowness of movement. 6. Marked disability even at the onset of symptoms.