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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.

PurposeAssessment of psychotherapeutic competence is increasingly regarded as important in the delivery of psychological services and training programmes. This article reviews tools designed to assess clinical competence in psychodynamic, interpersonal, and relational models of therapy.MethodsPsycINFO, CINAHL, and Web of Science online databases were reviewed using terms relating to competence, psychotherapy, and measurement. Titles and abstracts of all articles were screened, and full texts of remaining articles were read. Reference lists of included articles were also screened. Papers that described a measure of psychotherapeutic competence in a psychodynamic, interpersonal, or relational model, and reported at least one assessment of the reliability and/or validity of the measure, were included. The quality of the studies was evaluated, and the quality of individual measures was summarized.ResultsFourteen studies met the inclusion criteria, examining 13 competence measures for 12 specific models of therapy. Competence measures were not found for several NICE‐recommended models of therapy. Some measures demonstrated strengths in certain areas of reliability and validity; however, there were a number of quality issues in development and psychometric properties that suggest none of the measures are currently proven for widespread use.ConclusionsFurther research is required to refine currently existing measures and develop new measures for key NICE‐recommended models of therapy.Practitioner pointsAssessment and improvement of therapist competence is key to provision of high‐quality psychotherapeutic interventions.This review shows there are few measures of competence in relational therapy models and several NICE‐recommended models do not have corresponding competence measures.Measures that do exist are mixed in terms of their validity and reliability and should therefore be used with caution.

ObjectiveResponsiveness to direct verbal suggestions (suggestibility) has long been hypothesized to represent a predisposing factor for functional neurological disorder (FND) but previous research has yielded conflicting results. The aim of this study was to quantitatively evaluate whether FND patients display elevated suggestibility relative to controls via meta-analysis.MethodsFour electronic databases were searched in November 2019, with the search updated in April 2020, for original studies assessing suggestibility using standardized behavioural scales or suggestive symptom induction protocols in FND patients and controls. The meta-analysis followed Cochrane, PRISMA, and MOOSE guidelines. Data extraction and study quality coding were performed by two independent reviewers. Standardized suggestibility scores and responsiveness to symptom induction protocols were used to calculate standardized mean differences (SMDs) between groups.ResultsOf 26,643 search results, 19 articles presenting 11 standardized suggestibility datasets (FND: n = 316; control: n = 360) and 11 symptom suggestibility datasets (FND: n = 1285; control: n = 1409) were included in random-effects meta-analyses. Meta-analyses revealed that FND patients displayed greater suggestibility than controls on standardized behavioural scales (SMD, 0.48 [95% CI, 0.15, 0.81]) and greater responsiveness to suggestive symptom induction (SMD, 1.39 [95% CI, 0.92, 1.86]). Moderation analyses presented mixed evidence regarding the extent to which effect sizes covaried with methodological differences across studies. No evidence of publication bias was found.ConclusionsThese results corroborate the hypothesis that FND is characterized by heightened responsiveness to verbal suggestion. Atypical suggestibility may confer risk for FND and be a cognitive marker that can inform diagnosis and treatment of this condition.

This paper describes a condensed version of psychodynamic interpersonal therapy (PIT), Psychodynamic Interpersonal-Empathy (PI-E), which consists of the first level of competencies of the PIT model. The intention is to use basic psychodynamic principles and skills to enhance delivery of manualised, cognitive therapy based treatments. The intervention is designed to improve two common factors of therapy: the bond between client and therapist, and the ability of the therapist to create positive expectations through an explanation and understanding of the person’s problems. Both of these so-called common factors are consistently associated with clinical outcomes. Training has been developed specifically for low-intensity therapists who are employed in the Improving Access to Psychological Treatment programme. Training focuses upon 5 basic components of PI: negotiation; picking up cues;using statements rather than questions; focusing on feelings and understanding hypotheses. When used skilfully together, these simple components, offer a powerful way of empathizing with and deepening the collaborative work with the client. They all help the therapist to focus upon how the client is feeling ‘here and now’ in the session. Training in the model has the potential to improve outcomes and reduce drop-out rates by enabling therapists to manage problem scenarios in an empathic way.

Idiopathic environmental intolerance refers to a group of poorly understood health conditions characterized by heterogeneous somatic symptoms that occur in response to environmental triggers, but for which no physiological causes can be found. We focus on three varieties, namely symptoms attributed to (a) chemical substances, (b) electromagnetic fields, and (c) infrasound and vibroacoustic sources. As no clear link with organ pathology or dysfunction has been established so far, we review critical evidence about alternative causal mechanisms as a platform for a novel unifying model of these conditions. There is consistent evidence that expectancy and nocebo mechanisms are critically involved. Using recent predictive coding models of brain functioning, we describe a comprehensive new model to explain how symptoms come about and become linked to specific environmental cues. This new model integrates phenomenally different pathologies, suggests testable new hypotheses, and specifies implications for treatment.

Using the Internet to obtain health information (“online health research”, OHR) is commonplace. This paper provides a systematic narrative review of evidence concerning the relationship between OHR and health anxiety. We conclude that health anxiety is associated with more frequent self-reported OHR, heightened distress after OHR, and increased doctor visits post-OHR. Evidence suggests that OHR often has a reassurance seeking function and can relieve anxiety, but that it can also cause alarm and become a distressing, compulsive behaviour. We present a novel model that integrates these perspectives and existing research within a single explanatory framework that distinguishes between problematic OHR and compulsive OHR and describes the role of positive and negative metacognitions in their respective development.

Delusional disorder (DD) is still considered a diagnosis of exclusion for a difficult-to-treat condition characterised by the presence of delusional beliefs in the absence of other psychiatric symptoms. Attempts to contextualise psychological processes recognised since the earliest observations of this disorder have had very limited impact on improving some fixed beliefs. In the Cambridge Early Intervention in Psychosis Service we have observed a particular phenomenon, often categorised as a delusional idea in the context of DD, which manifests through highly repetitive belief expression that fails to respond to pharmacological and psychological treatments. Key aspects of this phenomenon are similar to those observed in dissociative (functional neurological) presentations. Drawing on the Integrative Cognitive Model of functional neurological disorders, we developed a successful psychological intervention that places less emphasis on challenging delusional content and focuses more on dismantling dissociation and underlying affective factors associated with the activation of the fixed belief. Our initial findings reinforce the need to continue developing a multi-level phenomenological approach to define a variety of symptoms traditionally grouped under the concept of “delusion.”

Aims/Objectives Impulse control behaviors (ICBs) affect 15%–35% of Parkinson’s Disease patients. There is evidence of increased carer strain due to these behaviours; however, little is known about clinical variables mediating this effect. This study aims to investigate the factors predictive of carer burden within a cohort of Parkinson’s Disease patients with ICBs. Identification of such factors may allow for targeted therapeutic intervention. Method Data was collected from 45 patients with clinically significant ICBs and their carers including levodopa equivalent daily dosage, assessments of motor and neuropsychiatric symptoms, cognitive function and ICBs. Carer burden was assessed using the Zarit Burden Interview (ZBI). Univariate analyses were performed using Spearman’s Rank Correlation Coefficient. A backward model was used to remove variables to create a final multivariate model using ZBI score as the dependent variable. Results Univariate analysis identified significant correlations between ZBI and total NPI (rs=0.50, p Conclusions This is the largest study to date, looking at associations between carer burden and ICBs. Our findings indicate low mood, poor motivation, social disinhibition and neuropsychiatric symptom burden to be significant factors in carer burden. We also observe that carers reporting poorer health had increased carer strain. Further work should explore methods of physical and psychosocial support and coping strategies for carers.

The current study aimed to explore the phenomenon of disease-related ‘query escalation’ in high/low health anxious Internet users ( N = 40). During a 15-minute health-related Internet search, participants rated their anxiety and the perceived seriousness of information on each page. Post-search interviews determined the reasons for, and effects of, escalating queries to consider serious diseases. Both groups were found to be significantly more anxious after escalating queries. The high group was significantly more likely to escalate queries. Evaluating personal relevance of material was the main reason for escalations and moderated anxiety post-escalation. We conclude that searching for online disease information can increase anxiety, particularly for people worried about their health.

Psychogenic Nonepileptic Seizures (PNES) superficially resemble epileptic seizures but are thoughtto have a psychological rather than epileptic basis. Patients with PNES vary widely in terms ofbackground, personality profiles, comorbidities, response to treatment and outcomes. Previousaccounts interpreting these seizures as the activation of dissociated material, a physical manifestationof emotional distress, hard-wired reflex responses, or learned behaviours cannot explain key featuresof the phenomenon. Drawing on a brief review of the literature on etiology, correlates andphenomenology of PNES, this paper integrates existing approaches and data within a novelexplanatory framework that applies to all PNES patients with subjectively involuntary seizures.Following the Integrative Cognitive Model of medically unexplained symptoms, we suggest that thecentral feature of all PNES is the automatic activation of a mental representation of seizures (the“seizure scaffold”) in the context of a high level inhibitory processing dysfunction. This often arisesin response to elevated autonomic arousal, and may disrupt the individual‟s awareness of distressingmaterial, but can become divorced from abnormal autonomic and emotional activity. This modelaccounts both for existing findings and the heterogeneity of patients with PNES, whilst leading to anumber of novel hypotheses against which it can be evaluated.

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Objective High symptom reporting (HSR) and medically unexplained symptoms (MUS) are associated with considerable distress, disability, healthcare utilization and costs, but are poorly understood, and current treatments are of limited benefit. Most models of HSR and MUS implicate cognitive-perceptual factors, such as increased body-focused attention, reduced perceptual thresholds and a tendency to experience somatic misperception, but little is known about the causal role of these variables. We investigated this issue by studying whether there is a longitudinal relationship between perceptual-attentional variables and later clinical outcomes in primary care patients. Method Primary care patients (N = 102) completed clinical (physical symptom reporting, health anxiety and healthcare utilization) and perceptual-attentional (body-focused attention, perceptual threshold, somatic misperception) measures at baseline and then again six months later (N = 72). Hierarchical regression was used to examine cross-lagged relationships between baseline and follow-up scores. Results Contrary to expectation, attending away from the body at baseline predicted increased not decreased symptom reporting six months later. Neither perceptual threshold nor somatic misperception predicted clinical outcomes at six months. Conclusions These findings suggest that body avoidance, rather than increased body focus, contribute to the development of HSR. Future studies should consider the potential clinical benefits of reducing bodily avoidance, via techniques that promote adaptive engagement with bodily sensations.

Aims and methodTo develop and pilot a clinician-rated outcome scale to evaluate symptomatic outcomes in liaison psychiatry services. Three hundred and sixty patient contacts with 207 separate individuals were rated using six subscales (mood, psychosis, cognition, substance misuse, mind–body problems and behavioural disturbance) plus two additional items (side-effects of medication and capacity to consent for medical treatment). Each item was rated on a five-point scale from 0 to 5 (nil, mild, moderate, severe and very severe).ResultsThe liaison outcome measure was acceptable and easy to use. All subscales showed acceptable interrater reliability, with the exception of the mind–body subscale. Overall, the measure appears to show stability and sensitivity to change.Clinical implicationsThe measure provides a useful and robust way to determine symptomatic change in a liaison mental health setting, although the mind–body subscale requires modification.Declaration of interestNone.

Psychological therapy is generally considered the treatment of choice for psychogenic nonepileptic seizures (PNES), but there is a paucity of research on patients' attitudes towards psychological referral. We conducted semistructured interviews with twelve patients with PNES awaiting psychological treatment in order to understand their perceived treatment needs. Data were analyzed inductively according to the principles of thematic analysis. The results indicated that our patients had clear ideas about their treatment needs and a desire to recover by 'returning to normality'. Many participants felt 'caught in limbo' following their PNES diagnosis, however, because of uncertainties about their condition and a lack of support from professionals. This linked with participants feeling unsure whether psychological treatment would meet their needs; there was also apprehension for some participants about the potential negative consequences of therapy. The clinical implications of these findings are discussed, and recommendations for future research are made.

Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label "conversion disorder" and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for "association of psychological factors" and the "exclusion of feigning" to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current 'disease exclusion' criteria to one in which the symptom must not be 'better explained' by a disease if present, (d) adding a 'cognitive symptoms' subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.

The current study aimed to obtain health anxious students’ perspectives on their reasons for using the Internet to obtain health information, and the nature and effects of such usage. Data were gathered using semi-structured interviews with 20 postgraduate and undergraduate students identified as highly health anxious, and were examined using thematic analysis. Results suggested that themes were organized by different stages of the search process. Reasons for searching included curiosity, anxiety/worry about undiagnosed symptoms, and remedy-seeking. Both positive (e.g. reassurance) and negative (e.g. uncertainty) outcomes were reported. Findings from the current study suggest that the Internet constitutes an important resource for obtaining health information by health anxious individuals, with the potential to both reduce and exacerbate health anxiety.

We present recommendations for revision of the diagnostic criteria for the Dissociative Disorders (DDs) for DSM-5. The periodic revision of the DSM provides an opportunity to revisit the assumptions underlying specific diagnoses and the empirical support, or lack of it, for the defining diagnostic criteria.This paper reviews clinical, phenomenological, epidemiological, cultural, and neurobiological data related to the DDs in order to generate an up-to-date, evidence-based set of DD diagnoses and diagnostic criteria for DSM-5. First, we review the definitions of dissociation and the differences between the definitions of dissociation and conceptualization of DDs in the DSM-IV-TR and the ICD-10, respectively. Also, we review more general conceptual issues in defining dissociation and dissociative disorders. Based on this review, we propose a revised definition of dissociation for DSM-5 and discuss the implications of this definition for understanding dissociative symptoms and disorders.We make the following recommendations for DSM-5: 1. Depersonalization Disorder (DPD) should include derealization symptoms as well. 2. Dissociative Fugue should become a subtype of Dissociative Amnesia (DA). 3. The diagnostic criteria for DID should be changed to emphasize the disruptive nature of the dissociation and amnesia for everyday as well as traumatic events. The experience of possession should be included in the definition of identity disruption. 4. Dissociative Trance Disorder should be included in the Unspecified Dissociative Disorder (UDD) category.There is a growing body of evidence linking the dissociative disorders to a trauma history, and to specific neural mechanisms.

This review by three established clinicians/researchers and two 'rising stars' in the field of psychogenic nonepileptic seizures (PNES) describes recent progress in this area and highlights priorities for future research. Empirically testable models of PNES are emerging but many questions about the aetiology of PNES remain unanswered at present. Video-EEG has made it possible for doctors to make secured diagnoses of PNES in more cases. However, unacceptable diagnostic delays and misdiagnoses are still common. Non-specific EEG changes are often misinterpreted as evidence of epilepsy. A better understanding of the symptomatology of PNES may allow earlier and more accurate diagnoses using self-report questionnaires. The communication of the diagnosis and the engagement of patient in psychological treatment can be difficult. A recent pilot RCT has demonstrated the effectiveness of a psychological treatment in reducing seizures in the short term, but longer-term effectiveness is yet to be demonstrated.

I have often argued that the construct of dissociation lacks clarity and that the term dissociation is widely used without consideration for its varied meanings and implications. I agree that more ...

Non-epileptic attack disorder (NEAD) poses a significant clinical problem but is poorly understood. Attachment theory provides a framework for understanding the development and maintenance of NEAD and the contribution of childhood abuse and neglect to these processes. A cross-sectional design was used to study attachment style and early traumatic experiences in individuals with NEAD (N=17) compared to those with epilepsy (N=26). A significant difference in predominant attachment style between the two groups was found, with fearful attachment occurring more frequently in the NEAD group. Abuse and neglect were also significantly more common in the NEAD patients. Both early traumatic experiences and fearful attachment added significantly to the predictive power of a logistic regression equation after controlling for anxiety and dysthymia. The findings suggest a link between disturbed attachment and NEAD and have clinical implications for therapeutic intervention with this group.

OBJECTIVE: High suggestibility is widely regarded as an important feature of patients with medically unexplained symptoms (MUS), particularly those with multiple MUS [i.e. somatization disorder (SD)], although there are few empirical data attesting to this assumption. A study was therefore conducted to compare levels of non-hypnotic suggestibility in patients with SD and medical controls. METHOD: A modified version of the Barber Suggestibility Scale was administered to 19 patients with SD and 17 controls with an established organic dystonia. RESULTS: Patients with SD were no more suggestible than control patients. Dystonia controls were more likely to deliberately comply with suggestions than the SD patients. CONCLUSION: Contrary to popular belief, high suggestibility is not necessarily a feature of SD.

OBJECTIVE: This study aimed to develop an experimental paradigm, using healthy controls, to measure change in tactile sensitivity and response bias for subsequent testing of patients with medically unexplained symptoms (MUS). METHODS: Participants judged whether or not they detected a weak tactile pulse (presented in 50% of trials). Performance in two conditions (tactile pulses presented with or without a concomitant light) was compared using signal detection analysis to assess whether a task-irrelevant light can invoke the sensation of touch, even in its absence. RESULTS: The results showed that the presence of a concurrent light significantly improved participants' detection of the tactile stimulus by 13.7% [t(18)=4.24, P

Pseudoneurological symptoms (i.e., conversion disorder), historically subsumed within the "hysteria" concept alongside phenomena such as psychogenic amnesia and multiple personality disorder, have been classified as somatoform disorders since DSM-III. Since then, there have been repeated calls to reclassify conversion disorder with the dissociative disorders, as in ICD-10. The authors review issues such as the high correlations between pseudoneurological and dissociative symptoms, the high rates of trauma reported for both groups, and the position that these phenomena share underlying processes. Although reintegrating pseudoneurological symptoms with the dissociative disorders is not without complications, there is a strong case for such a reclassification.

Patients with chronic medically unexplained symptoms (MUS) are frequently encountered in medical practice. Despite the distress, disability and resource utilization associated with MUS, these conditions remain poorly understood. This contribution describes a novel account of MUS that combines existing models in this area within a common explanatory framework based on cognitive psychological principles. According to the model, some MUS can be understood as distortions in bodily consciousness or control produced by the over-activation of symptom representations in memory. The primary goal of treatment is to minimize the repetitive re-allocation of attention onto symptoms that maintain this process.

Research suggests that inhibiting the effect of irrelevant stimuli on subsequent thought and action (cognitive inhibition) may be an important component of suggestibility. Two small correlation studies were conducted to address the relationship between different aspects of suggestibility and individual differences in cognitive inhibition, operationalized as the degree of negative priming generated by to-be-ignored stimuli in a semantic categorization task. The first study found significant positive correlations between negative priming, hypnotic suggestibility, and creative imagination; a significant negative correlation was obtained between negative priming and interrogative suggestibility, demonstrating the discriminant validity of the study results. The second study replicated the correlation between negative priming and hypnotic suggestibility, using a different suggestibility measurement procedure that assessed subjective experience and hypnotic involuntariness as well as objective responses to suggestions. These studies support the notion that the ability to engage in cognitive inhibition may be an important component of hypnotic responsivity and maybe of other forms of suggestibility.

Health-related Internet use has grown rapidly, yet little research has considered how health anxious individuals use the Internet for this purpose. Our aim was to examine the relationships between health anxiety and the extent of, reasons for, and consequences of health-related Internet usage in university students (n = 255). Responses on a purpose-made Internet use questionnaire were correlated with health anxiety scores; multiple regression analyses controlling for depression and anxiety were also conducted. Health anxiety positively correlated with (all ps < .01): frequency of health-related searching (r(s) = .163), proportion of health-related information sought (r(s) = .200), time spent online for health purposes (r(s) = .166), and number of searches for both illness (r(s) = .453) and wellness (r(s) = .208) information. Health anxiety further positively correlated with advantages perceived in health-related Internet use (r(s) = .183), heightened tension (r(s) = .364) and relief (r(s) = .174) post-search, and perceived doctor disadvantages (r(s) = .306), yet a greater likelihood to visit a doctor post-search (r(s) = .217). Health anxiety also correlated with six measures of possible addiction to using the Internet for health purposes (r(s) range = .171 to .366, all ps < .01). Some (including several potentially dysfunctional) aspects of health-related Internet use correlate with health anxiety. Research evaluating the possible role of Internet use in the development and maintenance of health anxiety is warranted.

To study the nature of personality and psychopathology in nonepileptic attack disorder (NEAD) and epilepsy, we prospectively assessed 45 consecutive attendees to a specialist assessment unit for epilepsy. Patients with NEAD were more likely to report clinically significant symptoms of anxiety, worry, disordered eating, and somatoform disorder. An ICD-10 diagnosis of anxiety or phobic disorder was significantly more common in NEAD patients. Together DSM-IV personality Clusters A and C were more common in epilepsy than NEAD. Hierarchical logistic regression with diagnosis as the target variable found anxiety, eating, and worry but not somatoform symptoms were reliably associated with NEAD. Together the Present State Examination (PSE) eating, PSE worrying/tension, PSE expansive mood, past psychiatric history, and gender variables allowed for correct classification of more than 88% of all cases. Personality and psychopathology variables seem to be valid clinical predictors of epilepsy and NEAD, and should be examined in epidemiological studies.

The suggestibility-enhancing effects of hypnosis are widely accepted, although poorly understood. In the present study, an attempt was made to address the effect of absorption and reduced critical thought on suggestibility change occurring in the hypnotic context. Study participants were presented with a waking suggestibility assessment followed by an induction consisting of instructions for progressive relaxation and a manipulation designed to establish an hypnotic context and an expectation for increased suggestibility. They were then presented with either further relaxation instructions, instructions to become absorbed or instructions to reduce critical thought, followed by a second suggestibility assessment. Groups were compared on objective and subjective suggestibility score change, controlling for suggestibility on the first test. Results indicate that the addition of instructions for absorption or reduced critical thought to relaxation procedures created a significantly larger suggestibility increase than instructions for relaxation alone. Moreover, instructions for relaxation alone were insufficient to produce an increase in suggestibility, despite the presence of an hypnotic context and positive expectations. These findings cast doubt on the notion that only non-state factors are responsible for suggestibility increases observed in the hypnotic context, and raise the possibility that absorption and reduced critical thought are important components of hypnosis. Copyright © 2001 British Society of Experimental and Clinical Hypnosis

The authors describe a study investigating the relationship between posthypnotic amnesia (PHA) and directed forgetting (DF) and their impact on implicit and explicit memory. This study adopted a recent modification of the process dissociation procedure to accommodate the cross-contamination of memory test performance by implicit and explicit memorial factors. Forty high and 40 low hypnotically susceptible participants were compared in PHA, DF, and control conditions on estimates of voluntary conscious (VCM), involuntary conscious (ICM), and involuntary unconscious memory (IUM) performance. Both groups showed significant decrements in VCM and ICM following instructions for DF, whereas only high susceptibles showed this decrement in the PHA condition; neither DF nor PHA affected IUM. Moreover, there was no relationship between forgetting in PHA and DF. Although both PHA and DF seem to prevent the conscious (i.e., explicit) expression of memorial information while leaving implicit memory intact, the...

It has been suggested that an everyday preference for holistic and emotional thought is related to the ability to enter hypnosis, although research addressing the idea has often yielded inconsistent results. This study correlated hypnotic susceptibility, as measured by the Harvard Group Scale (Shor and Orne, 1962), with three measures of a holistic/emotional thinking style: the experiential sub-scale of the Rational Versus Experiential Inventory (RVEI) (Epstein et al., 1995), the right hemisphere sub-scale of the Human Information Processing Survey (HIPS) (Taggart and Torrance, 1984) and the elaborative processing sub-scale of the Inventory of Learning Processes (ILP) (Schmeck et al., 1977). A social desirability measure was also included. Only the experiential scale of the RVEI and the social desirability scale showed significant positive correlations with susceptibility; a multiple regression analysis showed the RVEI scale to be the best predictor of susceptibility. The implications of these results for the analytic-holistic hypothesis in hypnosis are discussed. Copyright © 1998 British Society of Experimental and Clinical Hypnosis

Evidence for a shift from analytical to holistic processing during hypnosis is presented as a basis for a new conceptualization of hypnosis in terms of Epstein's integrative theory of personality, Cognitive-Experiential Self-Theory (CEST; e.g., Epstein, 1973, 1990, 1994). Support for this view comes from parallels between the hypnotic state and the experiential system as embodied in CEST and from converging lines of enquiry from cognitive psychology. It is concluded that there is significant heuristic value in such a conceptualization, which can form a framework within which to organize data and generate research, and can serve as an interface between cognitive psychology, the psychology of individual differences and hypnosis theory. Copyright © 1997 British Society of Experimental and Clinical Hypnosis

Objectives Psychogenic nonepileptic seizures (PNESs) are poorly understood and difficult to treat. Research and theory suggest that problems with recognizing, acknowledging, and regulating emotional states (i.e., emotional dysregulation) may contribute to the development and maintenance of PNESs. However, there is a lack of well-controlled studies using dedicated measures of emotional regulation with patients with PNESs. The current study sought to address this gap. Methods Forty-three patients with PNESs and 24 with epilepsy completed a postal survey comprising measures of emotional dysregulation (Difficulties in Emotion Regulation Scale), alexithymia (Toronto Alexithymia Scale), attachment (Relationship Scales Questionnaire), and psychopathology (Generalized Anxiety Disorder-7; Patient Health Questionnaire-9; Somatoform Dissociation Questionnaire-20). Cluster analysis was used to identify possible subgroups of patients with PNESs characterized by distinct patterns of emotional dysregulation. Results Two clusters of patients with PNESs were identified. The first (n = 11) was characterized by higher levels of psychopathology, somatization, alexithymia, and difficulties with most aspects of emotional regulation (including identifying, accepting, and describing feelings, accessing adaptive regulatory strategies, performing goal-directed behaviors, and controlling feelings and actions) compared with the group with epilepsy. The second (n = 32) was characterized by relatively high somatization and depression scores but comparatively normal levels of alexithymia and emotional regulation. Conclusions The findings suggest that patients with PNESs can be divided into at least two meaningful subgroups characterized by distinct psychological profiles, only one of which is characterized by significant problems with emotional dysregulation. Further research is needed to determine whether the relatively normal emotional dysregulation and high somatization scores of some patients with PNESs are due to emotional avoidance or more basic problems with perceptual and behavioral control.

Theory suggests that a tendency to experience distortions in somatosensory awareness is associated with physical symptom reporting (i.e., somatization) but empirical evidence for this is lacking. This article describes research designed to test this hypothesis.Somatosensory distortion was operationalized as the frequency of illusory touch experiences (i.e., false alarm rate) on the Somatic Signal Detection Task. Two studies correlated false alarms on this task with physical symptom reporting on the 15-item Patient Health Questionnaire, the first using a nonclinical sample (n = 35), the second using a clinical sample of endoscopy patients who were identified as having either medically explained (n = 25) or medically unexplained symptoms (n = 30).Scores on the 15-item Patient Health Questionnaire were positively correlated with false alarm rate in both studies (r = 0.288-0.506), even after controlling for trait anxiety, depression, anxiety (standardized β range = 0.793-0.932, all p.0001) and (in Study 2) somatosensory amplification and hypochondriacal worry (standardized β range = 0.345-0.375, both p.05). There was no difference in false alarm rate between patients with medically explained and medically unexplained symptoms (medically explained median range = 6.8 [3.7] to 6.8 [4.0] versus medically unexplained median range = 4.3 [3.9] to 5.6 [3.1], both p.1).There seems to be a robust link between physical symptom reporting and the tendency to experience somatosensory distortion, consistent with recent cognitive theories. It may be possible to reduce the impact of somatization by developing treatments that target this tendency.

This study formed part of an evaluation of a brief educational intervention for patients with psychogenic non-epileptic seizures (PNES). The sessions provide information, seizure control techniques and management planning. The qualitative component of the research reported here aimed to provide insight into the participants' perceptions following the intervention. Semi-structured interviews were conducted with twelve patients. Interviews were tape-recorded, transcribed and analyzed, using principles of thematic analysis. Six key themes were identified: getting answers; understanding the link with emotions; seeking a physiological explanation; doubting the diagnosis; the role of medication; and finding a way forward. The findings highlight considerable individual variation in response, with evidence of changed perceptions or enhanced understanding in some patients while others continued to seek answers or explanations about the cause of their seizures. There were no clear links between reported improved understanding or acceptance of the diagnosis and a perceived improvement in the condition.

Objective Medically unexplained symptoms (MUS) have been hypothesized to result from a distortion in perception, whereby top-down factors influence the process of body representation. Perceptual illusions provide a novel method of investigating this hypothesis. This study aimed to investigate whether self-reported unexplained symptoms are associated with altered experience of the rubber hand illusion (RHI). Methods A non-clinical MUS group with high scores on the Somatoform Dissociation Questionnaire (SDQ), and a control group with low scores on this scale, were exposed to the RHI. Illusion experience was measured by self-reports and by proprioceptive alteration. Results After controlling for somatosensory amplification and trait anxiety, the low-SDQ group responded significantly more strongly to the RHI on both questionnaire and proprioceptive measures of the illusion. In contrast, the high-SDQ group scored significantly higher on the Perceptual Aberrations Scale, a measure of bodily distortions in daily life. Conclusion These findings support the proposed link between MUS and disturbances in body representation, and suggest that a decreased reliance on current sensory inputs may contribute to symptom experience in susceptible individuals.

Objective: Unexplained neurological symptoms ("somatoform dissociation") are common in health care settings and associated with disproportionately high levels of distress, disability, and resource utilization. Theory suggests that somatoform dissociation is associated with disturbed attentional processing, but there is a paucity of research in this area and the available evidence is contradictory. Methods: We compared undergraduate participants (n=124) with high and low scores on the Somatoform Dissociation Questionnaire (SDQ-20) on a tactile cueing paradigm measuring the time course of attention to touch, following either a neutral film or a film designed to simulate the emotional effects of trauma exposure. Results: Following the neutral film, high SDQ-20 participants exhibited delayed disengagement from tactile cue stimuli compared to the low SDQ-20 group. Following the "trauma" film, however, the high SDQ-20 group showed attentional effects suggesting avoidance of the tactile stimuli in this condition. Early attention to tactile cues following the trauma film predicted film-related intrusive thoughts after the experiment. Conclusion: These findings suggest that both body vigilance and body avoidance may be involved in the expression of somatoform dissociation. © 2010 Elsevier Inc.

Objective The psychological mechanisms of somatoform dissociation (i.e., pseudoneurological symptoms) are poorly understood. This study evaluated recent theoretical predictions regarding the role of tactile perception in the development of somatoform dissociative symptoms. Methods Eighty nonclinical participants scoring either high or low on the Somatoform Dissociation Questionnaire (SDQ-20) completed the Somatic Signal Detection Task (SSDT), a novel perceptual paradigm designed to simulate the occurrence of somatoform symptoms in the laboratory. Prior to the SSDT, participants completed a memory task designed to produce either minimal or maximal activation of tactile representations in memory. Results The high SDQ-20 group exhibited a more liberal response criterion (c) on the SSDT than the low SDQ-20 group after controlling for negative affectivity, somatosensory amplification and depression. This effect was mainly attributable to an increased number of false alarms (i.e., illusory experiences of touch) in the high SDQ-20 group rather than an increased hit rate. General perceptual ability (i.e., tactile sensitivity) was comparable between the two groups. The memory manipulation had no effect on SSDT performance. Conclusions Somatoform dissociators appear more likely to experience illusory perceptual events under conditions of sensory ambiguity than nondissociators, despite comparable perceptual abilities more generally. These findings support theories that identify distorted perceptual processing as a feature of somatoform dissociation. The SSDT has potential as a tool for further research in this area.

This special issue is devoted to the topic of medically unexplained symptoms (MUS), a heterogeneous group of conditions characterized by persistent physical symptoms that cannot be explained by medical illness or injury. Although psychological factors have long been regarded as central to these problems, patients with MUS have typically been managed within medical settings and referrals to mental health services have been relatively rare. In recent years, however, interest in the psychological nature and treatment of MUS has expanded, culminating in the development of tailored psychological interventions for these conditions. This, coupled with the increasing willingness of practitioners to diagnose conditions such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome, has led to an increase in the number of patients who are referred for psychological treatment. At present, however, many psychological therapists are unfamiliar with the literature on MUS. With this in mind, this special issue presents a series of papers that provide an overview of what is known about the nature, aetiology and treatment of medically unexplained illness. This introductory paper provides general information about the clinical presentation, diagnosis, classification, terminology and epidemiology of MUS in adults, and concludes with an examination of important areas for future development in the field. Subsequent papers address the psychological mechanisms [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review; Iverson, A., Chalder, T., & Wessely, S. (2007-this issue). Gulf war illness: Lessons from medically unexplained illness. Clinical Psychology Review; Rief, W., & Broadbent, E. (2007-this issue). Explaining medically unexplained symptoms: Models and mechanisms. Clinical Psychology Review; Roelofs, K., & Spinhoven, P. (2007-this issue). Trauma and medically unexplained symptoms: Towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review] and management [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review] of these conditions. A separate overview of the literature on MUS in children and adolescents is provided by Eminson [Eminson, J. (2007-this issue). Medically unexplained symptoms in children and adolescents. Clinical Psychology Review].

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.

Objective Body-focused attention is regarded as an important maintaining factor for somatoform illness, although there is limited empirical evidence pertaining to this hypothesis. This study was conducted to assess whether individual differences in somatoform dissociation and somatosensory amplification were associated with biased attention towards the tactile modality, particularly following exposure to threatening body-related stimuli. Methods Forty-eight nonclinical participants completed the Somatoform Dissociation Questionnaire (SDQ-20; a proxy measure of somatoform symptomatology), the Somatosensory Amplification Scale (SSAS), and a modality bias task. The task consisted of a series of body-relevant or body-irrelevant (scene) picture stimuli, half of which were threatening and half were neutral, followed by target stimuli in either the visual or the tactile modality. Participants judged the location of each target stimulus, and performance data were used to calculate the degree to which participants were biased towards the tactile modality following each of the picture types. Results Participants in the high SDQ-20 group (defined by median split) showed a significant increase in tactile bias when responding to targets occurring 250 ms after the presentation of threatening body-relevant stimuli only. This effect was not observed for the low SDQ-20 group. Scores on the SSAS correlated negatively with tactile bias for both threatening and neutral body-relevant stimuli at 250 ms. Conclusions Individuals with a tendency to experience somatoform symptoms focus more on stimuli in the tactile modality immediately following exposure to threatening body-relevant information. In contrast, self-reported somatosensory amplification appears to be associated with attention away from the tactile modality rather than with increased tactile focus.

The term "dissociation" has been used to describe a wide range of psychological and psychiatric phenomena. The popular conception of dissociation describes it as a unitary phenomenon, with only quantitative differences in severity between the various dissociative conditions. More recently, it has been argued that the available evidence is more consistentwith amodel that identifies at least two distinct categories of dissociative phenomena-"detachment" and "compartmentalization"- that have different definitions, mechanisms and treatment implications (Holmes, Brown, Mansell, Fearon, Hunter, Frasquilho & Oakley 2005). This paper presents evidence for this bipartite model of dissociation, followed by definitions and descriptions of detachment and compartmentalization. Possible psychological mechanisms underlying these phenomena are then discussed, with particular emphasis on the nature of compartmentalization in conversion disorder, hypnosis, dissociative amnesia and dissociative identity disorder. Copyright © by The Haworth Press, Inc. All rights reserved.

The effects of practice on the serial performance of auditory and visual attention tasks were investigated in 10 healthy volunteers tested at 2 to 4 weekly intervals over eight test sessions using a battery of psychometric tests. Subjects as a group showed an ability to significantly (p = .05) improve their performances over time on all tests except for the Simple Reaction Time and Symbol Digit Modalities Test, the latter demonstrating a trend towards improvement (p = .07). Improvement when it occurred was almost uniformly linear and on tests such as the Pegboard and Stroop, was still discernable at the eighth session. On tests such as Paced Visual Serial Addition Task, floor effects were noted after five sessions and no further improvement was possible. In general, younger subjects tended to make fewer errors, perform quicker and improve for longer periods than their older counterparts. The results indicate that on tests of attention, healthy subjects have the ability to significantly improve performance with practice and this may extend over as many as eight discrete test sessions. The implications for neuropsychological research are discussed.