Neuropsychiatric disturbances have been known to be prevalent in dystonia patients. ^{Reference Lencer, Steinlechner and Stahlberg1,Reference Jahanshahi and Marsden2} Depression and anxiety have been reported in 25%–50% of dystonia patients. ^{Reference Moraru, Schnider and Wimmer3} Disruption of cortico-striato-thalamo-cortical circuits, responsible for dystonia, is also implicated in depression and anxiety and may contribute to co-existing psychiatric symptoms. ^{Reference Leisman, Braun-Benjamin and Melillo4}

A report by Rai et al. ^{Reference Rai, Tayade and Rai5} published in this journal has studied the prevalence of neuropsychiatric manifestations in patients with cervical dystonia (CD) and oromandibular dystonia (OMD), its association with dystonia severity and the impact on quality of life. They found that the prevalence of depression, anxiety, obsessive compulsive disorder and psychosis in the dystonia group was 37.9%, 29.3%, 4.3% and 2.1%, respectively, which were significantly lower compared to 9.9%, 7%, 1.4% and 0%, respectively, in the healthy control group. There was a significant association of depression with a worse Toronto Western Spasmodic Torticollis Rating Scale score. They also observed that reduced quality of life in CD is primarily driven by psychiatric comorbidity – especially depression, rather than motor severity or pain alone. The prevalence of psychiatric disorders in CD was higher, with depression at 43.5% and anxiety at 25.9%, compared to OMD, in which the prevalence of depression and anxiety was 28.2% and 35.2%, respectively.

These findings encourage clinicians to focus on neuropsychiatric aspects while dealing with dystonia patients. The knowledge of a greater susceptibility in certain dystonias, like CD, to developing neuropsychiatric issues could further improve overall patient care. A limitation of this study is that it excluded patients with neuropsychiatric symptoms preceding the onset of dystonia. Including such patients, and also the knowledge of the number of years by which these symptoms predate the onset of dystonia, would have given further valuable insights into the non-motor aspects of dystonia. It would be interesting to know how common it is for patients with milder dystonia to initially visit a psychiatric facility for disabling neuropsychiatric symptoms and then be referred to a neurologist for evaluation of dystonia, thereby highlighting the other end of the spectrum, which might have been missed due to the exclusion criteria.

Future efforts should focus on the preparation of guidelines for regular psychiatric screening of dystonia patients with objective tools. It would also be imperative to study the impact of treating dystonia alone on psychiatric symptoms. Additionally, functional imaging studies comparing dystonia patients with and without psychiatric symptoms would further throw light on the pathophysiological aspects.