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A Supportive Cognitive Behavioral Psychotherapeutic Treatment of Dystonia Symptoms

How Is Dystonia Treated?

Aggregated from professional sources by Dr. Mark Zuccolo July 20, 2020

Understanding Dystonia

The options to medically manage dystonic movements have traditionally been 4-fold; they consist of the following:

Rehabilitative therapies: Physical therapy techniques (e.g., massage), slow stretching, and physical modalities (e.g., ultrasonography, biofeedback) are sometimes helpful in individuals with focal or regional dystonias.

Oral prescription medications: Systemic medications benefit approximately one third of patients and consist of a wide variety of options, including cholinergics, benzodiazepines, antiparkinsonism drugs, anticonvulsants, baclofen, carbamazepine, and lithium. Successful drug therapy often requires combinations of several medications, with choices generally guided by empirical trials and adverse effect profiles. 

Neurochemolytic interventions: Botulinum toxins or phenol/alcohol injections have become powerful tools in improving the symptomatic treatment of focal dystonias. These injections temporarily reduce the ability of the muscles to contract and may be the treatment of choice for blepharospasm, cervical dystonia, and hemifacial spasm.

Surgery: Surgical options for intractable dystonias include transection of the spinal accessory nerve for cervical dystonia; stereotactic thalamotomy or pallidotomy for generalized dystonia; and muscle excision, lengthening, or transfer. Because of the risk of significant comorbidity, these approaches are reserved for patients with disabling dystonia in whom other treatment modalities have been exhausted.

Psychological counseling, psychotherapy (such as Dr. Z's CBT-based supportive approach), and participation in support groups are vital adjuncts to medical and physical approaches in the multidisciplinary management of dystonia.

Oral Prescription Medications

The following medications are often given to individuals suffering from dystonia. They must be prescribed by a physician and taken under clinical supervision.

Anticholinergics  
benzotropine, biperidin, ethopropazine, ophenadrine, procyclidine, trihexyphenidyl

Dopaminergics  
levodopa, pramipexole, ropinirole, tetrabenazine

GABAergics
alprazolam, baclofen, chlordiazepoxide, clonazepam, diazepam

Muscle “relaxants”  
baclofen, benzodiazepines, carisoprodol, chlorzoxazone, cyclobenzeprine, metaxolone, methocarbamol, orphenadrine

Others  
carbamazepine, cannabidiol, cyproheptidine, gabapentin, lithium, mexilitine, nabilone, riluzole, tizanidine, zolpidem

Medical Therapies for Specific Dystonias

Many of following dystonias occur in infancy, childhood or adolescence. They must be treated medically and supported by CBT psychotherapy.

Abetalipoproteinemia (Bassen-Kornzweig)  
Onset at childhood to early adulthood, progressive oromandibular or generalized dystonia, ataxia, chorea, retinitis pigmentosa, fat malabsorption. Treated with vitamin E, reduced fat diet.

Aromatic amino acid decarboxylase deficiency  
Onset in infancy, generalized dystonia with developmental delay, hypotonia, oculogyric crises, autonomic dysfunction. Treated with dopamine agonists, monoamine oxidase inhibitors.

Ataxia with vitamin E deficiency  
Onset in childhood to early adulthood, rarely patients present with dystonia instead of ataxia or neuropathy. Treated with vitamin E.

Autoimmune movement disorders  
Onset at any age, focal or generalized dystonia, systemic signs of autoimmune disease. Treated by addressing the autoimmune process.

Biotinidase deficiency  
Onset in infancy, generalized dystonia with developmental delay, encephalopathy, seizures, sensory defects, skin rash. Treated with biotin.

Cerebral folate deficiency  
Onset in early childhood to adolescence, progressive dystonia with developmental delay, neuropsychiatric syndromes, seizures. Treated with folinic acid.

Cerebrotendious xanthomatosis  
Onset in late childhood to adulthood, oromandibular or limb dystonia, neurocognitive defects, spasticity, myoclonus, tendon xanthomas. Treated with chenodeoxycholic acid.

Cobalamin deficiencies (inherited sub-types A-G)  
Onset in infancy, generalized dystonia with developmental delay, ataxia, spasticity, seizures, bone marrow defects. Treated with cobalamin derivatives and/or protein restriction.

CoEnzyme Q10 deficiency  
Onset at any age, some cases present with dystonia and ataxia, affects varied phenotypes, most often progressive ataxia or encephalopathy. Treated with coenzyme Q10.

Cerebral creatine deficiency type 3  
Onset in infancy, generalized dystonia with developmental delay, myopathy. Treated with  creatine.

Dopa-responsive dystonia, classic  
Onset in early childhood to late adulthood, generalized dystonia also known as Parkinsonism. Treated with levodopa.

Dopa-responsive dystonia, complicated  
Onset in infancy to adolescence, generalized dystonia, hypokinetic-rigid syndrome, oculogyric crises, autonomic dysfunction. Treated with levodopa, 5-hydroxytryptophan, and/or tetrahydrobiopterin.

Dystonia with brain manganese accumulation
Onset in childhood, progressive generalized dystonia, Parkinsonism, liver disease, polycythemia. Treated with chelation therapy.

Galactosemia
Onset in childhood to early adulthood, mild focal or generalized dystonia, ataxia, tremor, food intolerance. Treated with lactose restriction.

GLUT1 deficiency  
Onset in childhood to adolescence, paroxysmal exertional dystonia, developmental delay, seizures. Treated with ketogenic diet.

Glutaric aciduria type 1
Onset in early childhood to early adulthood, static generalized dystonia following encephalopathic crisis, developmental delay, encephalopathic crisis. Treated aggressively with focus on any inter-current illness, lysine restriction.

Homocystinuria  
Onset in childhood, generalized or paroxysmal dystonia, neurocognitive dysfunction, myopia, ectopic lens. Treated with methionine restriction.

Guanidinoacetate methyltransferase deficiency  
Onset in infancy, progressive generalized dystonia, developmental delay, seizures. Treated with  arginine restriction, creatine and ornithine.

"Maple syrup" urine disease  
Onset in childhood, focal or paroxysmal dystonia, neonatal encephalopathy, ataxia. Treated with  leucine restriction, ±thiamine.

Methylmalonic aciduria  
Onset in childhood, static generalized dystonia following encephalopathic crisis, developmental delay, encephalopathic crisis, renal insufficiency, pancytopenia. Treated aggressively with focus on any inter-current illness, protein restriction.

Molybdenum cofactor deficiency (sulfite oxidase)  
Onset in adolescence, rarely patients present with dystonia and parkinsonism, developmental delay, encephalopathy, seizures. Treated with cyclic pyranopterin monophosphate.

Niemann Pick type C 
Onset in early childhood to early adulthood, progressive generalized dystonia, dementia, ataxia, spasticity, seizures, supranuclear gaze palsy. Treated with N-butyl-deoxynojirimycin (Miglustat™).

Paraneoplastic movement disorders
Onset at any age, rapidly progressive focal or generalized dystonia, cancer malignancy, often occult. Treated by addressing the underlying malignancy.

Propionic aciduria  
Onset in early childhood to adolescence, static generalized dystonia following encephalopathic crisis, developmental delay, encephalopathic crisis, optic atrophy, pancytopenia. Treated aggressively focusing on any inter-current illness, protein restriction.

Pyruvate dehydrogenase deficiency  
Onset in infancy, progressive generalized or paroxysmal dystonia, developmental delay, seizures. Treated with thiamine, ketogenic diet, dichloroacetate. 

Rapid onset dystonia-Parkinsonism  
Onset in early childhood to late adulthood, bulbar or generalized dystonia following encephalopathic crisis, psychomotor disability. Treated aggressively with focus on any inter-current illness, protein restriction.

Wilson’s disease  
Onset in early childhood to late adulthood, progressive generalized dystonia, neurocognitive dysfunction, liver disease, Kayser-Fleischer rings. Treated with zinc, tetrathiomolybdenate.

Complementary Supportive Therapies

The following complementary and supportive therapies are available to individuals suffering from dystonia. They must be administered by trained practitioners or licensed clinicians.

Cognitive-Behavioral Therapy
CBT is a form of psychotherapeutic treatment that is a vitally necessary adjunct to medical and physical approaches in the multidisciplinary management of dystonia. CBT can significantly improve the effectiveness of medical treatments and ameliorate the psychological distress associated with this condition.

Acupuncture
It involves insertion of fine needles. Acupuncture stimulates the nerves in the skin, muscle and other tissues, and can produce a variety of effects. 

Hypnosis
It is a psychological technique used in medicine as a tool to bring about positive changes to both the mind and the body. It is often accompanied by deep physical relaxation, increased inner focus and a corresponding reduction in the awareness of your surroundings. 

Reflexology
It involves applying pressure to the feet and hands. The application of pressure to parts of the feet or the hands effect corresponding parts of the body through reflex zones and meridian points. 

Autogenic Training (Meditation)
It is a structured meditative-style practice. It is a sequence of simple mental exercises which bring about profound mental and physical relaxation. 

Homeopathy
It is based on the idea of treating ‘like with like’. Key features of homeopathy include: Holism (‘treating the person, not the disease’), Constitution (focusing on the type of person, including build, personality, general physical features), Idiosyncrasy (focus on what is unusual about the patient and their health problem), Minimum dose (concentrated tinctures to extremely diluted medicines). 

Craniosacral Therapy
It is a gentle ‘hands-on’ therapy that aims to release tensions, restrictions and misalignments in the body.