Psychogenic Blepharospasm

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Identifier 923-6
Title Psychogenic Blepharospasm
Ocular Movements Frequent blinking
Creator Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School, Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Contributor Primary Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Subject Psychogenic Blepharospasm; Lid Twitch; Voluntary Blinking; Blepharospasm
Supplementary Materials PowerPoint Presentation: Blepharospasm Round Up: Shirley H. Wray, M.D., Ph.D., FRCP, Harvard Medical School
Presenting Symptom Frequent eyelid blinking and "twinking"
History The patient is a 57 year old woman who presented in 1989, with a 3 year history of frequent eyelid blinking, twitching and twinking. She was under a good deal of stress and anxiety attributed to moving house after 26 years and losing touch with her friends and social activities. She was also concerned that her husband, at the age of 58, had taken early retirement. The onset of frequent blinking initially coincided with her wearing contact lenses and was attributed to dry eyes. Although she was embarrassed by the frequent eyelid blinking, it did not interrupt her volunteer work, social engagements, driving or watching television. She noted no involuntary movements of her lower face or muscles elsewhere and denied taking antidepressant medications or tranquilizers. Past history negative for the use of narcoleptic drugs. Family history negative for blepharospasm, dystonia and neurodegenerative disease.
Clinical This patient with psychogenic blepharospasm is seen after three years of intensive psychotherapy and treatment for depression without the use of narcoleptic drugs. The video shows that she still has frequent eyelid and eyebrow blinking but no spasms of lid closure on squeezing the lids. She has no involuntary movements of the lower face. The correct documentation of the clinical eyelid examination should include: 1. Observe the eyes and face when taking the history 2. Assess lid position in different gaze directions 3. Look for blepharoclonus on gentle eye closure 4. Count the blink rate 5. Check for suppression of blepharospasm by visual attention (OKN drum) 6. Look for positive Glabella tap - An inability to inhibit a blink when the forehead is tapped and 7. Pay attention to the latency and speed of voluntary vertical and horizontal eye movements on command. The differential diagnosis, in this case, is bengin essential blepharospasm due to focal dystonia of the eyelids. (See ID 945-4)
Anatomy The dynamics of normal eyelid blinking depends on a key muscle -- the levator palpebrae superioris muscle which elevates the lid. This muscle, often referred to as the 7th extraocular muscle, is significantly different from the extraocular muscles in that it contains only singly-innervated fibres of the types suitable for fatigue-resistant tonic activity. The motor neurons that activate the levator are located in a single midline central caudal nucleus of the 3rd nerve complex in the midbrain and the levator is innervated by the superior branch of the 3rd nerve. The levator acting alone controls: 1. Tonic lid elevation to keep the eyes open and 2. Voluntary eye closure and eye opening. Two further muscles, innervated by the facial nerve, act on the eyelid: The frontalis muscle which helps to retract the lid in extreme upward gaze, and the orbicularis oculi muscle which controls periodic and reflex blinking and firm eye closure in protective and expressive acts like sneezing. In all kinds of blinks the levator is abruptly inhibited to allow the eyes to close and then it resumes its prior level of activity once the contraction of the palpebral portion of the orbicularis oculi, closing the eyelids momentarily, is over. Conversely, the orbicularis oculi activity precedes and outlasts the levator inhibition in firm eye closure. The brain's control of the eyelids is major. The cerebral cortex (R>L) controls the tonic activity of the levator and voluntary eye opening and eye closure. The dynamics of normal blinks, spontaneous and voluntary, and the frequency of periodic blinks depend on the affective, attentional and cognitive state of the patient. During sleep and when the eyes are gently closed, activity of the levator ceases completely. The extrapyramidal dopaminergic circuit influences the execution of blinks and blink frequency and the basal ganglia play a role in the inhibition of the levator during blinks and eye closure.
Pathology N/A
Etiology Psychogenic Blepharospasm - Stress Related
Disease/Diagnosis Psychogenic Blepharospasm - Anxiety/Depression
Treatment The patient was treated for depression. When last seen in 1991 after completing 3 year course of psychotherapy she reported that she felt "absolutely marvelous" and able to control her eyelid blinking.
References 1) Averbuch-Heller L. Neurology of the eyelids. Current Opinion in Ophthalmology 1997; 8:27-34. 2. Boghen D. The apraxia of lid opening: a review. Neurology 1997; 48: 1491-1603. 3. Hallett M. Blepharospasm: recent advances. Neurology. 2002 Nov 12; 59 (9): 1306-12. Review. 4. Schmidtke K, Buttner-Ennever JA. Nervous Control of Eyelid Function. A review of clinical, experimental and pathological data. Brain 1992; 115: 227-247. 5. Wray SH. Blepharospasm Roundup. The 23rd Annual International Benign Essential Blepharospasm Research Foundation Scientific Symposium, Park City, Utah. August 2005.
Relation is Part of 161-5, 946-4
Contributor Secondary Steve Smith, Videographer; Ray Balhorn, Digital Video Compressionist
Reviewer Dr. Mark Hallett, Dr. Dan Boghen - 2005
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 1990
Type Image/MovingImage
Format video/mp4
Source 3/4" Umatic master videotape
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit:
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL
Language eng
ARK ark:/87278/s6fv1hmt
Setname ehsl_novel_shw
Date Created 2005-08-22
Date Modified 2021-05-06
ID 188542
Reference URL