Search

Functional neurological disorder (FND) is a common and disabling disorder that is often considered difficult to treat, particularly in adults. Psychological therapies are often recommended for FND. Outcome research on psychological therapies for FND has grown in recent years but has not been systematically evaluated since 2005. This study aims to build on that by systematically reviewing the evidence-base for individual outpatient cognitive behavioural and psychodynamic psychotherapies for FND. Medical databases were systematically searched for prospective studies of individual outpatient psychotherapy for FND with at least five adult participants. Studies were assessed for methodological quality using a standardised assessment tool. Results were synthesised, and effect sizes calculated for illustrative purposes. The search strategy identified 131 relevant studies, of which 19 were eligible for inclusion: 12 examining cognitive behavioural therapy (CBT) and 7 investigating psychodynamic therapy (PDT). Eleven were pre–post studies and eight were randomised controlled trials. Most studies recruited a single symptom-based subtype rather than all presentations of FND. Effect sizes, where calculable, showed generally medium-sized benefits for physical symptoms, mental health, well-being, function and resource use for both CBT and PDT. Outcomes were broadly comparable across the two therapy types, although a lack of high-quality controlled trials of PDT is a significant limitation, as is the lack of long-term follow-up data in the majority of identified CBT trials. In conclusion, both CBT and PDT appear to potentially offer some benefit for FND, although better quality studies are needed.

The latest edition of the International Classification of Diseases (ICD-10)1 defines dissociation as “ . . . a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of body movements” (p 151). Thus defined, the concept of dissociation captures a heterogeneous group of psychiatric conditions previously subsumed within the broader construct of hysteria. The dissociative (conversion) disorders category in ICD-10 comprises subcategories of dissociative amnesia, dissociative fugue, trance and possession disorders, dissociative anaesthesia and sensory loss, dissociative motor disorders and dissociative convulsions, and waste basket categories included to capture uncommon, impure, or less severe instances of dissociation. Other symptoms previously viewed as hysterical are placed within the somatoform disorders category of ICD-10, on the grounds that their primary characteristic is an apparent disturbance of bodily rather than cerebral function. By contrast, DSM-IV2 classifies convulsions, motor dysfunction, and sensory loss as somatoform disorders, despite adopting an otherwise similar definition of dissociation and categorisation of dissociative complaints. In the context of this editorial we embrace the more inclusive scheme offered by ICD-10. The basis for their inclusion within current psychiatric nosology is the assumption that dissociative disorders are primarily psychological in nature.1 Nevertheless, the concept of dissociation has important implications for practice and research within the neurological sphere also. Dissociative psychopathology was witnessed almost exclusively within the neurological setting until the late 19th and early 20th centuries, and many such patients present to neurologists even now. What is striking about dissociative symptoms is their apparent similarity to those found in many common neurological conditions, and it is often extremely difficult to distinguish between the two; the case of dissociative convulsions provides an instructive example. Recent estimates suggest that between 9% and 50% of patients referred to specialist …

To assess the relationship between the behavioural triad of hyper-religiosity, hypergraphia and hyposexuality in epilepsy, and volumes of the mesial temporal structures.Magnetic resonance images were obtained from 33 patients with refractory epilepsy and mesial temporal structure volumes assessed. Amygdala and hippocampal volumes were then compared in high and low scorers on the religiosity, writing, and sexuality sub-scales of the Neurobehavioural Inventory.Patients with high ratings on the religiosity scale had significantly smaller right hippocampi. Religiosity scores rated by both patient and carer showed a significant negative correlation with right hippocampal volumes in this group. There were no other differences in amygdala or hippocampal volumes between these groups, or between high and low scorers on the writing and sexuality sub-scales.These findings suggest that right hippocampal volumes are negatively correlated with religiosity in patients with refractory epilepsy.

Objective We describe the roll-out of a brief psycho-education intervention for individuals with non-Epileptic Attack Disorder (NEAD), which has been developed for healthcare professionals with limited experience in delivering psychological treatments. Method The psycho-education package is comprised of four one-to-one sessions. The first session provides an explanation of the NEAD diagnosis and introduces the patient to idea that mind and body are linked. The second session teaches behavioural strategies for controlling seizures, including sensory grounding, relaxation and imagery. The third session focuses on identifying and reducing avoidance behaviours that may have been adopted due to seizure symptoms. The final session focuses on values and going forward. Eighteen nurses and therapists attended a training to deliver this package. The two day training intervention included lectures and interactive workshops with actors. The initial roll out stage involved fourteen NHS trusts across the country. Ten months following training, therapists were asked to complete a survey to assess the extent they used this intervention and that they found it to be relevant, comprehensive, and sufficient. Patients with NEAD who attended for psycho-education were also asked to complete pre and post questionnaires including the following measures; Work and Social Adjustment scale (WSAS), Brief Illness Perception Questionnaire (Brief IPQ), Clinical outcomes in routine evaluation (CORE) and the EuroQoL-5D3L and NewQOL quality of life measures. Results Since the training, the package has been delivered in four centres. Recruitment and data collection are ongoing. Preliminary analysis of the pre and post participant data shows that following intervention, participants viewed their seizures as significantly less threatening (IPQ, p=0.002), and reported significantly less distress (CORE, p=0.01) The collection of therapist feedback about the use of the intervention is ongoing. Conclusion It is feasible for healthcare professionals with minimal training in psychological intervention to deliver a brief psycho-education package for individuals with NEAD. Further analysis is needed to understand the full effectiveness of this intervention but preliminary results show that this intervention may have positive effects on the way individuals view their seizures and on their overall wellbeing.

Aims Apathy is a neurocognitive syndrome of reduced goal-directed behaviour, which is an important cause of disability in neurodegenerative disorders. We aimed to test the hypothesis that apathy in two disorders would be associated with reduced activation in the dorsolateral prefrontal cortex and supplementary motor area during a novel fMRI paradigm specifically examining volitional behaviour. Methods A new fMRI paradigm, designed to avoid confounding by working memory and to be easy for patients to perform, was first used in a group of 15 healthy volunteers. 21 patients with Progressive Supranuclear Palsy and 20 patients with Alzheimer9s disease provided data for the clinical study. Patients were defined as apathetic or non-apathetic by a Clinical Global Impression of Apathy, based on the use of established rating scales. These sub-groups were well-matched for important demographic and clinical characteristics and all patients were able to perform the task successfully. Results As expected, healthy volunteers showed increased activation in the DLPFC and SMA during self-initiated compared with cued actions. Using a conservative whole brain analysis, there were no significant differences in activation associated with self-initated action between apathetic and non-apathetic patients. However, using a hypothesis-driven region of interest approach we found significantly reduced activation among apathetic patients in the DLPFC (in both PSP and AD) and in the SMA (in PSP only). Conclusions These findings support the notion that deficits in self-initiated behaviour are a key part of the cognitive basis of apathy symptoms and that altered function in the DLPFC and SMA may be important in the neurobiology of apathy across different neurological disorders.