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Purpose: Little is known about the accuracy of the GAD-7, a self-report anxiety measure, in detecting generalised anxiety disorder (GAD) in people with dissociative seizures (DS). We evaluated the reliability, validity and uniformity of the GAD-7 using a diagnosis of GAD on the Mini-International Neuropsychiatric Interview as a reference. Methods: We assessed 368 adults with DS at the pre-randomisation phase of the CODES trial. Factor analysis for categorical data assessed GAD-7 uniformity. Diagnostic accuracy was assessed by estimating the area under the curve (AUC). We evaluated discriminant validity, reviewed data on convergent validity and calculated internal consistency. We explored correlations between GAD-7 scores and monthly DS frequency, frequency of severe seizures and measures of behavioural and emotional avoidance. Results: Internal consistency of the GAD-7 was high (α = 0.92). Factor analysis elicited one main factor and general measurement invariance. Diagnostic accuracy was fair (AUC = 0.72) but the best balance of sensitivity and specificity occurred at a cut-off of ≥12 and still had a specificity rate of only 68%. Discriminant and convergent validity were good. GAD-7 scores correlated positively with DS frequency, severe seizure frequency, behavioural and emotional avoidance (all p < 0.001). Conclusion: Findings regarding internal consistency and factor structure parallel previous psychometric evaluations of the GAD-7. Correlations between GAD-7 scores and DS occurrence/severity and avoidance are evidence of the concept validity of GAD-7 and provide further support for a fear-avoidance treatment model for DS. However, the utility of the GAD-7 as a diagnostic instrument for generalised anxiety disorder is limited in patients with DS.

Clinical interest in using psychological interventions for people with epilepsy (PWE) aiming at decreasing mental health difficulties, improving health-related quality of life (HRQOL) and seizure-related outcomes, continues to grow. This article summarizes the 2020 update of the 2017 Cochrane Review and meta-analysis of psychological interventions for PWE, highlighting the reasons for major methodological modifications such as the recategorization of interventions and expanded risk of bias assessment. A 2020 literature search yielded 36 RCTs (n=3526) investigating psychological treatments for PWE with a validated HRQOL measure as an outcome. Twenty-seven trials were skills-based psychological interventions, whilst nine studies were education-only interventions. Among skills-based psychological interventions, 11 studies (n=643) used the Quality of Life in Epilepsy-31 (QOLIE-31) or other QOLIE inventories convertible to QOLIE-31 as an outcome measure and were pooled for meta-analysis. Significant mean changes were observed for the QOLIE-31 total score (mean improvement of 5.23 points; p< 0.001) and in six out of seven subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication and cognitive functioning). The mean changes in the QOLIE-31 total score and the overall QoL subscale exceeded the threshold of minimally important change (MIC), indicating clinically meaningful post-intervention improvement. These results provide moderate evidence that psychological treatments for adults and adolescents with epilepsy enhance HRQOL. In addition to the summary of the Cochrane review, we provide a detailed characterization of the interventions and patient populations of the meta-analyzed studies.

Background Studies have reported elevated rates of dissociative symptoms and comorbid dissociative disorders in functional neurological disorder (FND); however, a comprehensive review is lacking. Aims To systematically review the severity of dissociative symptoms and prevalence of comorbid dissociative disorders in FND and summarise their biological and clinical associations. Method We searched Embase, PsycInfo and MEDLINE up to June 2021, combining terms for FND and dissociation. Studies were eligible if reporting dissociative symptom scores or rates of comorbid dissociative disorder in FND samples. Risk of bias was appraised using modified Newcastle–Ottawa criteria. The findings were synthesised qualitatively and dissociative symptom scores were included in a meta-analysis (PROSPERO CRD42020173263). Results Seventy-five studies were eligible (FND n = 3940; control n = 3073), most commonly prospective case–control studies (k = 54). Dissociative disorders were frequently comorbid in FND. Psychoform dissociation was elevated in FND compared with healthy (g = 0.90, 95% CI 0.66–1.14, I2 = 70%) and neurological controls (g = 0.56, 95% CI 0.19–0.92, I2 = 67%). Greater psychoform dissociation was observed in FND samples with seizure symptoms versus healthy controls (g = 0.94, 95% CI 0.65–1.22, I2 = 42%) and FND samples with motor symptoms (g = 0.40, 95% CI −0.18 to 1.00, I2 = 54%). Somatoform dissociation was elevated in FND versus healthy controls (g = 1.80, 95% CI 1.25–2.34, I2 = 75%). Dissociation in FND was associated with more severe functional symptoms, worse quality of life and brain alterations. Conclusions Our findings highlight the potential clinical utility of assessing patients with FND for dissociative symptomatology. However, fewer studies investigated FND samples with motor symptoms and heterogeneity between studies and risk of bias were high. Rigorous investigation of the prevalence, features and mechanistic relevance of dissociation in FND is needed.

Given the significant impact epilepsy may have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is increasing clinical interest in evidence-based psychological treatments, aimed at enhancing psychological and seizure-related outcomes for this group. This is an updated version of the original Cochrane Review published in Issue 10, 2017.To assess the impact of psychological treatments for people with epilepsy on HRQOL outcomes.For this update, we searched the following databases on 12 August 2019, without language restrictions: Cochrane Register of Studies (CRS Web), which includes randomized or quasi-randomized controlled trials from the Specialized Registers of Cochrane Review Groups including Epilepsy, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to 09 August 2019), and PsycINFO (EBSCOhost, 1887 onwards), and from PubMed, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We screened the references from included studies and relevant reviews, and contacted researchers in the field for unpublished studies.We considered randomized controlled trials (RCTs) and quasi-RCTs for this review. HRQOL was the main outcome. For the operational definition of 'psychological treatments', we included a broad range of skills-based psychological treatments and education-only interventions designed to improve HRQOL, seizure frequency and severity, as well as psychiatric and behavioral health comorbidities for adults and children with epilepsy. These psychological treatments were compared to treatment as usual (TAU), an active control group (such as social support group), or antidepressant pharmacotherapy.We used standard methodological procedures expected by Cochrane.We included 36 completed RCTs, with a total of 3526 participants. Of these studies, 27 investigated skills-based psychological interventions. The remaining nine studies were education-only interventions. Six studies investigated interventions for children and adolescents, three studies investigated interventions for adolescents and adults, and the remaining studies investigated interventions for adults. Based on satisfactory clinical and methodological homogeneity, we pooled data from 11 studies (643 participants) that used the Quality of Life in Epilepsy-31 (QOLIE-31) or other QOLIE inventories (such as QOLIE-89 or QOLIE-31-P) convertible to QOLIE-31. We found significant mean changes for the QOLIE-31 total score and six subscales (emotional well-being, energy and fatigue, overall QoL, seizure worry, medication effects, and cognitive functioning). The mean changes in the QOLIE-31 total score (mean improvement of 5.23 points, 95% CI 3.02 to 7.44; P0.001), and the overall QoL score (mean improvement of 5.95 points, 95% CI 3.05 to 8.85; P0.001) exceeded the threshold of minimally important change (MIC: total score: 4.73 points; QoL score: 5.22 points), indicating a clinically meaningful postintervention improvement in HRQOL. We downgraded the certainty of the evidence provided by the meta-analysis due to serious risks of bias in some of the included studies. Consequently, these results provided moderate-certainty evidence that psychological treatments for adults with epilepsy may enhance overall HRQOL.Implications for practice: Skills-based psychological interventions improve HRQOL in adults and adolescents with epilepsy. Adjunctive use of skills-based psychological treatments for adults and adolescents with epilepsy may provide additional benefits in HRQOL when these are incorporated into patient-centered management. We judge the evidence to be of moderate certainty.Investigators should strictly adhere to the CONSORT guidelines to improve the quality of reporting on their interventions. A thorough description of intervention protocols is necessary to ensure reproducibility. When examining the effectiveness of psychological treatments for people with epilepsy, the use of standardized HRQOL inventories, such as the Quality of Life in Epilepsy Inventories (QOLIE-31, QOLIE-31-P, and QOLIE-89) would increase comparability. Unfortunately, there is a critical gap in pediatric RCTs and RCTs including people with epilepsy and intellectual disabilities. Finally, in order to increase the overall quality of RCT study designs, adequate randomization with allocation concealment and blinded outcome assessment should be pursued. As attrition is often high in research that requires active participation, an intention-to-treat analysis should be carried out. Treatment fidelity and treatment competence should also be assessed. These important dimensions, which are related to 'Risk of bias' assessment, should always be reported.배경: 간질이 간질을 가진 개인과 그 가족의 건강 관련 삶의 질(HRQOL)에 상당한 영향을 미칠 수 있다는 점을 고려할 때, 이 집단의 심리적 및 발작 관련 결과 제고를 목적으로 하는 근거 기반 심리치료에 대한 임상적 관심이 증가하고 있다. 이것은 2017년 이슈 10에 게재된 오리지널 코크란 리뷰의 업데이트 버전이다. 목적: 간질을 가진 사람들의 심리 치료법이 HRQOL 결과에 미치는 영향을 평가한다. 검색 전략: 이 업데이트를 위해 언어 제한 없이 2019년 8월 12일에 다음 데이터베이스를 검색했다. CRS 웹(Cochrane Register of Studies, CRS Web)은 간질, Cochrane Central Register of Controlled Trials(중앙), MEDLINE(Ovid, 1946년 ~ 2019년 8월) 및 PycINFO(EBSCO 호스트, 1887년)를 포함한 코크란 검토 그룹의 전문 레지스터에서 무작위 또는 준 무작위 관리 시험을 포함한다.inicalTrials.gov 및 세계보건기구(WHO) 국제임상시험 등록 플랫폼(ICTRP). 포함된 연구와 관련 리뷰의 참고자료를 선별하고, 미발표 연구를 위해 해당 분야의 연구자에게 연락했다. 선정 기준: 이 검토를 위해 무작위 대조 시험(RCT)과 준 RCT를 고려했다. HRQOL이 주된 결과였다. '정신적 치료'의 운영적 정의를 위해, HRQOL, 발작 빈도 및 중증도를 개선하기 위해 고안된 광범위한 기술 기반의 심리 치료와 교육 전용 중재, 그리고 간질을 앓고 있는 성인과 어린이들을 위한 정신과 행동 건강 이상 등을 포함시켰다. 이러한 심리 치료는 평상시와 같은 치료법(TAU), 능동적인 통제집단(사회지원집단 등), 또는 항우울제 약리치료법과 비교되었다. 자료 수집 및 분석: 코크란이 기대하는 표준 방법론적 절차를 사용했다. 주요 결과: 총 3526명의 참가자와 함께 36개의 완성된 RCT를 포함했다. 이들 연구 중 27개 연구팀이 기술 기반의 심리 중재를 조사했다. 나머지 9개 연구는 교육 전용 중재였다. 아동·청소년의 중재를 조사한 연구도 6건, 청소년·성인의 중재를 조사한 연구도 3건, 성인의 중재를 조사한 연구도 남아 있었다. 만족스러운 임상 및 방법론적 동질성을 바탕으로 간질 31(QOLIE‐31) 또는 QOLIE‐31로 전환된 다른 QOLIE 재고(QOLIE‐89 또는 QOLIE‐31‐P)를 사용한 11개 연구(643명 참여자)의 데이터를 취합했다. QOLIE‐31 총점과 6개 항목별 판매(감정 웰빙, 에너지 및 피로, 전체 QoL, 발작 우려, 약물 효과, 인지 기능)에 대한 평균적인 변화를 발견했다. QOLIE‐31 총점(5.23점, 95% CI 3.02~7.44점, P0.001점), 전체 QoL 점수(5.95점, 95% CI 3.05~8.85점, P0.001)의 평균 변동은 최소 중요 변화 한계치(MIC: 총점)를 초과했다. 4.73점, QoL 점수: 5.22점))는 HRQOL의 임상적으로 의미 있는 사후 중재 개선을 나타낸다. 포함된 일부 연구에서 편향의 심각한 위험 때문에 메타분석이 제공하는 근거의 확실성을 하향조정했다. 결과적으로, 이러한 결과는 간질을 가진 성인에 대한 심리치료가 전반적인 HRQOL을 향상시킬 수 있다는 중간 정도의 확실성 근거를 제공했다. 연구진 결론: 실무에 대한 의미: 기술 기반의 심리적 중재는 간질을 가진 성인과 청소년의 HRQOL을 개선한다. 간질이 있는 성인과 청소년을 위한 기술기반 심리치료의 부수적 사용은 환자 중심의 관리에 통합될 때 HRQOL에서 추가적인 혜택을 제공할 수 있다. 그 근거가 어느 정도 확실하다고 판단한다. 연구에 대한 시사점: 수사관들은 그들의 중재에 대한 보고의 질을 향상시키기 위해 연방 수사국 지침을 엄격히 준수해야 한다. 재현성을 확보하기 위해서는 중재 프로토콜에 대한 철저한 설명이 필요하다. 간질 환자 심리치료의 효과를 조사할 때, 간질재고(QOLIE‐31, QOLIE‐31‐P, QOLIE‐89)와 같은 표준화된 HRQOL 재고를 사용하면 비교가능성이 높아질 것이다. 불행히도 간질과 지적장애를 가진 사람들을 포함한 소아 RCT와 RCT에는 심각한 격차가 있다. 마지막으로, RCT 연구 설계의 전반적인 품질을 높이기 위해서는 할당 은폐 및 블라인드 결과 평가를 통한 적절한 무작위화가 추진되어야 한다. 적극적인 참여가 필요한 연구에서는 소모가 높은 경우가 많으므로 치료의향 분석을 실시해야 한다. 치료 충실도와 치료 능력도 평가해야 한다. '비뚤림의 위험' 평가와 관련된 이러한 중요한 차원은 항상 보고되어야 한다.پیشینه: با توجه به تاثیر عمده بیماری صرع بر کیفیت زندگی مرتبط با سلامت (health‐related quality of life; HRQOL) افراد مبتلا به صرع و خانواده‌های آنها، علاقه بالینی به درمان‌های روانشناختی مبتنی بر شواهد، با هدف بهبود پیامد‌های روانشناختی و مرتبط با تشنج، برای این گروه، رو به افزایش است. این یک نسخه به‌روز‌ شده از مرور اصلی کاکرین است که در شماره 10، سال 2017 منتشر شده است. اهداف: ارزیابی تاثیر درمان‌های روانشناختی افراد مبتلا به صرع بر پیامد‌های HRQOL. روش‌های جست‌وجو: در 12 آگوست 2019، برای آخرین نسخه به‌روز، بانک‌های اطلاعاتی زیر را بدون اعمال محدودیت‌های زبانی جست‌وجو کردیم: پایگاه ثبت مطالعات کاکرین (CRS Web)، شامل مطالعات تصادفی‌سازی یا شبه‐تصادفی‌سازی شده و کنترل شده از پایگاه ثبت تخصصی گروه مرور کاکرین از جمله بیماری صرع، پایگاه ثبت مرکزی کارآزمایی‌های کنترل‌ شده کاکرین (CENTRAL)؛ MEDLINE؛ (Ovid؛ 1946 تا 09 آگوست 2019)؛ PsycINFO؛ (EBSCOhost؛ 1887 به بعد)؛ و از PubMed؛ Embase؛ ClinicalTrials.gov؛ و پلت‌فرم بین‌المللی پایگاه ثبت کارآزمایی‌های بالینی (ICTRP) سازمان جهانی بهداشت. منابع مربوط به مطالعات وارد شده و مرور‌های مرتبط را غربال کردیم و برای شناسایی مطالعات منتشر نشده با محققان این حوزه تماس گرفتیم. معیارهای انتخاب: کارآزمایی‌های تصادفی‌سازی و کنترل شده (randomised controlled trials; RCTs) و شبه‐RCTها را برای ورود به این مرور در نظر گرفتیم. پیامد اصلی HRQOL بود. برای تعریف عملی «درمان‌های روانشناختی»، طیف گسترده‌ای از درمان‌های مبتنی بر مهارت و مداخلات صرفا آموزشی طراحی شده برای بهبود HRQoL، فراوانی و شدت تشنج (seizure) و نیز اختلالات روانپزشکی و سلامت رفتاری برای بزرگسالان و کودکان مبتلا به صرع را در نظر گرفتیم. این درمان‌های روانشناختی، با درمان به‌طور معمول (treatment as usual; TAU)، و گروه کنترل فعال (مانند گروه حمایت اجتماعی)، یا دارو‌درمانی ضد‐افسردگی مقایسه شدند. گردآوری و تجزیه‌وتحلیل داده‌ها: از روش‌های استاندارد روش‌شناسی مورد انتظار کاکرین استفاده کردیم. نتایج اصلی: 36 RCT کامل شده، با مجموع 3526 شرکت‌کننده را وارد کردیم. از بین این مطالعات، 27 مطالعه مداخلات روانشناختی مبتنی بر مهارت را بررسی کردند. نه مطالعه باقیمانده فقط مداخلات مربوط به آموزش بودند. شش مطالعه، مداخلات مربوط به كودكان و نوجوانان، سه مطالعه مداخلات مربوط به نوجوانان و بزرگسالان و مطالعات دیگر مداخلات مربوط به بزرگسالان را مورد بررسی قرار دادند. بر مبنای همگنی روش‌شناسی و بالینی، داده‌های 11 مطالعه (643 شرکت‌کننده) را که از کیفیت زندگی در صرع ‐31 (QOLIE‐31) یا سایر پرسش‌نامه‌های QOLIE (مانند QOLIE‐89 یا QOLIE‐31‐P) قابل تبدیل به QOLIE‐31 استفاده کرده‌ بودند، تجمیع کردیم. میانگین تغییرات قابل توجهی را برای نمره کل QOLIE‐31 و شش مقیاس (بهزیستی (well‐being) عاطفی، انرژی و خستگی، QoL کلی، نگرانی تشنج، تاثیرات دارویی و عملکرد شناختی) یافتیم. میانگین تغییرات نمره کل QOLIE‐31 (میانگین بهبود 5.23 نمره؛ 95% CI؛ 3.02 تا 7.44؛ P0.001) و QoL کلی (میانگین بهبود 5.95 نمره؛ 95% CI؛ 3.05 تا 8.85؛ P0.001) بیش از آستانه حداقل تغییرات مهم بود: (MIC: نمره کل: 4.73 امتیاز؛ نمره QoL: 5.22 امتیاز)، که نشان دهنده یک بهبود معنا‌دار بالینی در HRQOL بود. قطعیت شواهد ارائه شده در متاآنالیز (meta‐analysis) را به دلیل خطر جدی سوگیری (bias) در برخی مطالعات وارد شده، پائین درنظر گرفتیم. در‌نتیجه، این نتایج شواهدی با قطعیت متوسط ارائه کردند که نشان می‌داد درمان‌های روانشناختی برای بزرگسالان مبتلا به صرع ممکن است HRQOL کلی را در افراد مبتلا به صرع افزایش دهد. نتیجه‌گیری‌های نویسندگان: کاربردهای عملی: مداخلات روانشناختی مبتنی بر مهارت، HRQOL را در بزرگسالان و نوجوانان مبتلا به صرع بهبود می‌بخشد. استفاده کمکی از درمان‌های روانشناختی برای بزرگسالان و نوجوانان مبتلا به صرع ممکن است مزایای بیش‌تری برای HRQOL در افرادی فراهم‌ آورد که مدیریت بیمار‐محور را در نظر می‌گیرند. شواهد را دارای قطعیت متوسط قضاوت کردیم. کاربردهای تحقیقاتی: محققان باید دقیقا از دستورالعمل‌های CONSORT برای بهبود کیفیت گزارش‌های مربوط به مداخلات پیروی کنند. توصیف کامل پروتکل مداخله برای اطمینان از تکرار‌پذیری ضروری است. هنگام بررسی اثربخشی درمان‌های روانشناختی برای افراد مبتلا به صرع، استفاده از پرسش‌نامه استاندارد شده HRQOL؛ از جمله پرسش‌نامه کیفیت زندگی در صرع (QOLIE‐31؛ QOLIE‐31‐P و QOLIE‐89) قابلیت مقایسه را افزایش می‌دهد. متاسفانه یک شکاف جدی در RCTهای مربوط به کودکان و RCTهای افراد مبتلا به صرع و ناتوانی‌های فکری وجود دارد. در نهایت، به منظور افزایش کیفیت کلی طرح‌های مطالعاتی، در زمان انجام RCTها باید تصادفی‌سازی مناسب با پنهان‌سازی تخصیص و ارزیابی کورسازی شده پیامد پیگیری شوند. به دلیل این‌که در اغلب پژوهش‌هایی که نیاز به مشارکت فعال شرکت‌کننده دارند، ریزش نمونه (attrition) بالاست، یک آنالیز قصد درمان (intention‐to‐treat) باید انجام شود. تعهد به درمان و کفایت درمان نیز باید ارزیابی شود. این ابعاد مهم، که به ارزیابی «خطر سوگیری (bias)» مربوط می‌شوند، باید همیشه گزارش شوند.Étant donné l'impact significatif que l'épilepsie peut avoir sur la qualité de vie liée à la santé (QVLS) des personnes épileptiques et de leurs familles, il existe un intérêt clinique croissant pour les traitements psychologiques basés sur des données probantes visant à améliorer les critères de jugement psychologiques et liés aux crises pour ce groupe. Ceci est une version mise à jour de la revue Cochrane originale publiée dans le numéro 10, 2017.Évaluer l'impact des traitements psychologiques pour les personnes épileptiques sur la QVLS. STRATÉGIE DE RECHERCHE DOCUMENTAIRE: Pour cette mise à jour, nous avons effectué des recherches dans les bases de données suivantes et sans restrictions de langues jusqu’au 12 août 2019: Le Registre Cochrane des études (CRS Web), qui comprend des essais contrôlés randomisés ou quasi randomisés provenant des registres spécialisés des groupes de revues Cochrane, dont celui sur l’épilepsie, le registre Cochrane des essais contrôlés (CENTRAL), MEDLINE (Ovid, de 1946 au 9 août 2019) et PsycINFO (EBSCOhost, à partir de 1887), ainsi que PubMed, Embase, ClinicalTrials.gov et le Système d'enregistrement international des essais cliniques (ICTRP) de l'OMS. Nous avons examiné les références des études incluses et des revues pertinentes, et nous avons contacté des chercheurs dans le domaine pour des études non publiées. CRITÈRES DE SÉLECTION: Nous avons pris en compte les essais contrôlés randomisés (ECR) et les quasi‐ECR pour cette revue. La QVLS en a été le principal critère de jugement. Pour la définition opérationnelle de « traitement psychologiques », nous avons inclus un large éventail de traitements psychologiques basés sur les compétences, et d'interventions éducatives conçues pour améliorer la QVLS, la fréquence et la gravité des crises, ainsi que les comorbidités psychiatriques et comportementales pour les adultes et les enfants épileptiques. Ces traitements psychologiques ont été comparés au traitement habituel (TH), à un groupe témoin actif (tel qu'un groupe de soutien social) ou à une pharmacothérapie antidépressive. RECUEIL ET ANALYSE DES DONNÉES: Nous avons suivi les procédures méthodologiques standard définies par Cochrane. RÉSULTATS PRINCIPAUX: Nous avons inclus 36 ECR terminés, avec un total de 3 526 participants. Parmi ces études, 27 portaient sur des interventions psychologiques basées sur les compétences. Les neuf autres études étaient des interventions à caractère éducatif uniquement. Six études ont porté sur les interventions auprès des enfants et des adolescents, trois sur les interventions auprès des adolescents et des adultes, et les autres sur les interventions auprès des adultes. Sur la base d'une homogénéité clinique et méthodologique satisfaisante, nous avons mis en commun les données de 11 études (643 participants) qui ont utilisé le questionnaire sur la qualité de vie en cas d'épilepsie (QOLIE‐31) ou d'autres questionnaires QOLIE (tels que QOLIE‐89 ou QOLIE‐31‐P) convertibles en QOLIE‐31. Nous avons constaté des changements moyens significatifs pour le score total de QOLIE‐31 et pour six sous‐échelles (bien‐être émotionnel, énergie et fatigue, qualité de vie globale, inquiétudes liées aux crises, effets des médicaments et fonctionnement cognitif). Les changements moyens du score total de QOLIE‐31 (amélioration moyenne de 5,23 points, IC à 95 %, de 3,02 à 7,44 ; P0,001), et du score global de QV (amélioration moyenne de 5,95 points, IC à 95 %, de 3,05 à 8,85 ; P0,001) ont dépassé le seuil de changement important minimal (MIC) (MIC : score total : 4,73 points ; score de la qualité de vie: 5,22 points), ce qui indique une amélioration cliniquement significative de la qualité de vie liée à la santé après l'intervention. Nous avons déclassé le niveau de confiance des données probantes fournies par la méta‐analyse en raison de risques sérieux de biais dans certaines des études incluses. Par conséquent, la valeur probante de ces résultats était modérée à propos de l’amélioration de la qualité de vie globale chez les adultes épileptiques par les traitements psychologiques.Implications pour la pratique: Les interventions psychologiques basées sur les compétences améliorent la qualité de vie des adultes et des adolescents épileptiques. L'utilisation complémentaire de traitements psychologiques basés sur les compétences chez les adultes et les adolescents épileptiques pourrait apporter des avantages supplémentaires en matière de qualité de vie liée à la santé lorsque ceux‐ci sont intégrés dans une gestion centrée sur le patient. Nous estimons que le niveau de confiance des données probantes est modéré. Implications pour la recherche: Les enquêteurs doivent se conformer strictement aux recommandations CONSORT afin d'améliorer la qualité des rapports sur leurs interventions. Une description complète des protocoles d'intervention est nécessaire pour assurer la reproductibilité. Lors de l'examen de l'efficacité des traitements psychologiques pour les personnes souffrant d'épilepsie, l'utilisation de questionnaires standardisés sur la qualité de vie, tels que les questionnaires sur la qualité de vie dans l'épilepsie (QOLIE‐31, QOLIE‐31‐P et QOLIE‐89), permettrait d'accroître la comparabilité. Malheureusement, il existe une lacune importante dans les ECR pédiatriques et les ECR incluant les personnes souffrant d'épilepsie et de handicap intellectuel. Enfin, afin d'améliorer la qualité globale des plans d'étude des ECR, il convient de poursuivre une randomisation adéquate avec assignation secrète et évaluation des critères de jugement en aveugle. Comme le taux d'attrition est souvent élevé dans les recherches qui nécessitent une participation active, il convient de procéder à une analyse des intentions de traitement. La fidélité au traitement et la compétence en matière de traitement doivent également être évaluées. Ces dimensions importantes, qui sont liées à l'évaluation du « risque de biais », devraient toujours être signalées.Debido al impacto significativo que podría tener la epilepsia sobre la calidad de vida relacionada con la salud (CdVRS) en los individuos con epilepsia y sus familias, hay un creciente interés clínico en los tratamientos psicológicos basados en evidencia, dirigidos a mejorar los desenlaces psicológicos y relacionados con las crisis para este grupo de personas. Esta es una versión actualizada de la revisión Cochrane original publicada en el número 10, 2017.Evaluar los efectos de los tratamientos psicológicos para los pacientes con epilepsia en los resultados de la CdVRS. MÉTODOS DE BÚSQUEDA: Para esta actualización, se realizaron búsquedas en las siguientes bases de datos el 12 de agosto de 2019 sin restricciones de idioma: La Cochrane Register of Studies (CRS Web),que incluye ensayos controlados aleatorizados o cuasialeatorizados del registro especializado de los Grupos Cochrane de Revisión de Epilepsia, Cochrane Central de Ensayos Controlados (CENTRAL), MEDLINE (Ovid, 1946 a 9 de agosto de 2019), y PsycINFO (EBSCOhost, 1887 en adelante), y de PubMed, EMBASE, ClinicalTrials.gov y la plataforma de registros internacionales de ensayos clínicos (ICTRP) de la Organización Mundial de la Salud. Se examinaron las referencias de los estudios incluidos y las revisiones pertinentes, y se estableció contacto con los investigadores del tema para obtener estudios no publicados. CRITERIOS DE SELECCIÓN: Se consideraron los ensayos controlados aleatorizados (ECA) y los ensayos controlados cuasialeatorizados para esta revisión. La CdVRS fue el desenlace principal. Para la definición operativa de “tratamientos psicológicos”, se incluyó un rango amplio de tratamientos psicológicos basados en habilidades e intervenciones solo educativas diseñadas para mejorar la CdVRS, la frecuencia y la gravedad de las crisis, y las comorbilidades psiquiátricas y conductuales para los adultos y los niños con epilepsia. Estos tratamientos psicológicos se compararon con el tratamiento habitual (TH), un grupo de control activo (como el grupo de apoyo social) o la farmacoterapia antidepresiva. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Se utilizaron los procedimientos metodológicos estándares previstos por Cochrane.Se incluyeron 36 ECA completos con 3526 participantes. De estos, 27 estudios investigaron intervenciones psicológicas basadas en habilidades. Los nueve estudios restantes fueron intervenciones solo educativas. Seis estudios investigaron intervenciones para niños y adolescentes, tres estudios investigaron intervenciones para adolescentes y adultos, y los restantes investigaron intervenciones en adultos. De acuerdo con una homogeneidad clínica y metodológica satisfactoria, se agruparon los datos de 11 estudios (643 participantes) que utilizaron la escala para medir la calidad de vida en la epilepsia Quality of Life in Epilepsy‐31 (QOLIE‐31) u otros listados QOLIE (como el QOLIE‐89 o el QOLIE‐31‐P) convertibles a QOLIE‐31. Se encontraron cambios medios significativos para la puntuación total de la QOLIE‐31 y seis subescalas (bienestar emocional, energía y fatiga, CdV general, preocupación sobre la crisis, efectos de la medicación y función cognitiva). Los cambios medios en la puntuación total de la QOLIE‐31 (mejora media de 5,23 puntos, IC del 95%: 3,02 a 7,44; P0,001), y la puntuación global de la CdV (mejora media de 5,95 puntos, IC del 95%: 3,05 a 8,85; P0,001) superaron el umbral de cambio mínimo importante (CMI: puntuación total: 4,73 puntos; puntuación de CdV: 5,22 puntos), lo que indica una mejoría posintervención clínicamente significativa en la CdVRS. La certeza de la evidencia aportada por el metanálisis se redujo debido a riesgos graves de sesgo en algunos de los estudios incluidos. En consecuencia, estos resultados aportaron evidencia de certeza moderada de que los tratamientos psicológicos para los adultos con epilepsia pueden mejorar la CdVRS general.Implicaciones para la práctica: Las intervenciones psicológicas basadas en habilidades mejoran la CdVRS en adultos y adolescentes con epilepsia. El uso adyuvante de terapias psicológicas basadas en habilidades para los adultos y adolescentes con epilepsia podría proporcionar beneficios adicionales a la CdVRS cuando se incorporan a un tratamiento centrado en el paciente. Se consideró que la evidencia era de certeza moderada. Implicaciones para la investigación: Los investigadores deben adherirse estrictamente a las guías CONSORT para mejorar la calidad del informe sobre las intervenciones. Una descripción minuciosa de los protocolos de intervención es necesaria para asegurar la reproducibilidad. Cuando se examina la efectividad de los tratamientos psicológicos para los pacientes con epilepsia, el uso de listados estandarizados de CdVRS (QOLIE‐31, QOLIE‐31‐P, y QOLIE‐89) aumentaría la comparabilidad. Por desgracia, existe una laguna crítica en los ECA pediátricos y ECA que incluyen a personas con epilepsia y discapacidades intelectuales. Finalmente, para aumentar la calidad general de los diseños de estudio de ECA, debe aplicarse una asignación al azar adecuada con ocultación de la asignación y una evaluación de resultados cegada. Debido a que la deserción a menudo es alta en la investigación que requiere la participación activa, debe realizarse un análisis de intención de tratar. También deben evaluarse la fidelidad al tratamiento y la competencia del tratamiento. Estas importantes dimensiones, relacionadas con la evaluación del "riesgo de sesgo", deben ser siempre comunicadas.

Summary Objectives The Psychology Task Force of the Medical Therapies Commission of the International League Against Epilepsy (ILAE) has been charged with taking steps to improve global mental health care for people with epilepsy. This study aimed to inform the direction and priorities of the Task Force by examining epilepsy healthcare providers’ current practical experiences, barriers, and unmet needs around addressing depression and anxiety in their patients. Methods A voluntary 27‐item online survey was distributed via ILAE chapters and networks. It assessed practices in the areas of screening, referral, management, and psychological care for depression and anxiety. A total of 445 participants, from 67 countries (68% high income), commenced the survey, with 87% completing all components. Most respondents (80%) were either neurologists or epileptologists. Results Less than half of respondents felt adequately resourced to manage depression and anxiety. There was a lack of consensus about which health professionals were responsible for screening and management of these comorbidities. About a third only assessed for depression and anxiety following spontaneous report and lack of time was a common barrier (>50%). Routine referrals to psychiatrists (>55%) and psychologists (>41%) were common, but approximately one third relied on watchful waiting. A lack of both trained mental health specialists (>55%) and standardized procedures (>38%) was common barriers to referral practices. The majority (>75%) of respondents’ patients identified with depression or anxiety had previously accessed psychotropic medications or psychological treatments. However, multiple barriers to psychological treatments were endorsed, including accessibility difficulties (52%). Significance The findings suggest that while the importance of managing depression and anxiety in patients with epilepsy is being recognized, there are ongoing barriers to effective mental health care. Key future directions include the need for updated protocols in this area and the integration of mental health professionals within epilepsy settings.

Most neuroimaging modalities use regular grids of voxels to represent the three-dimensional space occupied by the brain. However, a regular 3D voxel grid does not reflect the anatomical and topological complexity represented by the brain’s white matter connections. In contrast, tractography reconstructions based on diffusion MRI provide a closer characterisation of the white matter pathways followed by the neuronal fibres interconnecting different brain regions. In this work, we introduce hypervoxels as a new methodological framework that combines the spatial encoding capabilities of multidimensional voxels with the anatomical and topological information found in tractography data. We provide a detailed description of the framework and evaluate the benefits of using hypervoxels by carrying out comparative voxel and hypervoxel cluster inference analyses on diffusion MRI data from a neuroimaging study on amyotrophic lateral sclerosis (ALS). Compared to the voxel analyses, the use of hypervoxels improved the detection of effects of interest in the data in terms of statistical significance levels and spatial distribution across white matter regions known to be affected in ALS. In these regions, the hypervoxel results also identified specific white matter pathways that resolve the anatomical ambiguity otherwise observed in the results from the voxel analyses. The observed increase in sensitivity and specificity can be explained by the superior ability of hypervoxel-based methods to represent and disentangle the anatomical overlap of white matter connections. Based on this premise, we expect that the use of hypervoxels should improve the analysis of neuroimaging data when the effects of interest under investigation are expected to be aligned along distinct but potentially overlapping white matter pathways.

PURPOSE: The CODES Trial for adults with dissociative seizures had a predesignated 12-month post-randomisation follow-up point for outcome evaluation. We undertook an exploratory, unplanned, secondary analysis to evaluate the effectiveness of cognitive behavioural therapy plus standardised medical care (CBT+SMC) compared to SMC alone at 6 months post-randomisation, i.e., closer to the end of treatment.METHODS: The analysis of 6-month data followed our previous method of using multiple imputation and an intention-to-treat approach to analyse variables 12 months post-randomisation.RESULTS: The original trial primary outcome of monthly seizure frequency showed greater benefit from CBT+SMC than SMC-alone at 6 months (at p < 0.05). Of 13 comparable previously-defined secondary outcomes, 12 showed a significant between group effect (p < 0.05) in favour of the CBT intervention at 6 months. The average effect size of the comparable previously-defined primary and secondary continuous outcomes was 0.33 at 6 months vs 0.26 at 12 months. The estimated Incidence Rate Ratio (IRR) quantifying monthly seizure reduction was IRR = 0.72 (95%CI from 0.55 to 0.93) at 6 months compared to IRR = 0.78 at 12 months.CONCLUSION: DS-specific CBT (plus SMC) produced evidence of significant benefits at 6 months post- randomisation (around which time CBT was complete) compared to SMC alone; for the majority of these outcomes, better results following CBT (plus SMC) had previously been reported at 12 months. Our pattern of results suggests that short- and longer-term follow-ups are necessary to understand treatment effects in this disorder. Studies only providing short-term follow-up data should be interpreted with caution.

Objective To characterize disease evolution in amyotrophic lateral sclerosis using an event‐based model designed to extract temporal information from cross‐sectional data. Conventional methods for understanding mechanisms of rapidly progressive neurodegenerative disorders are limited by the subjectivity inherent in the selection of a limited range of measurements, and the need to acquire longitudinal data. Methods The event‐based model characterizes a disease as a series of events, each comprising a significant change in subject state. The model was applied to data from 154 patients and 128 healthy controls selected from five independent diffusion MRI datasets acquired in four different imaging laboratories between 1999 and 2016. The biomarkers modeled were mean fractional anisotropy values of white matter tracts implicated in amyotrophic lateral sclerosis. The cerebral portion of the corticospinal tract was divided into three segments. Results Application of the model to the pooled datasets revealed that the corticospinal tracts were involved before other white matter tracts. Distal corticospinal tract segments were involved earlier than more proximal (i.e., cephalad) segments. In addition, the model revealed early ordering of fractional anisotropy change in the corpus callosum and subsequently in long association fibers. Interpretation These findings represent data‐driven evidence for early involvement of the corticospinal tracts and body of the corpus callosum in keeping with conventional approaches to image analysis, while providing new evidence to inform directional degeneration of the corticospinal tracts. This data‐driven model provides new insight into the dynamics of neuronal damage in amyotrophic lateral sclerosis.

Objectives/AimsDissociation is a potential mechanism in FND. Although scientific studies report elevated rates of dissociative symptoms in FND, a systematic assessment of the biological and clinical correlates of dissociation in FND is lacking. We aimed to systematically review the current evidence describing dissociative symptoms and disorders in functional neurological disorder (FND), and additionally conduct a meta-analysis of dissociative symptom severity in FND. We also aimed to synthesise the existing data on biological and clinical correlates of dissociation in FND.MethodsWe systematically searched Embase, PsycINFO, and Medline, combining terms for FND and dissociation. Studies were eligible for inclusion if reporting on dissociative symptom scale scores or rates of dissociative disorder in FND samples. Studies were appraised for methodological quality using modified Newcastle-Ottawa criteria. Findings pertaining to dissociative symptoms or disorders, as well as biological and clinical correlates of dissociation in FND samples, were synthesised qualitatively. Dissociative symptom scores were included in a meta-analysis using random and mixed effects models.ResultsTwo-thousand and eighty-eight records were screened and seventy-nine studies were included in the final review. Dissociative symptoms were elevated in FND. The meta-analysis demonstrated a significant elevation in dissociation in FND samples relative to neurological and healthy controls, but not psychiatric controls. Dissociative disorders were frequently co-morbid in FND samples. Psychoform (cognitive) dissociation was more prominent in FND-seizures, whereas somatoform (physical) dissociation tended to be more prominent in FND-motor symptom samples. Dissociation was associated with FND symptom severity or frequency, general psychopathology, and reduced quality of life. Biological correlates of elevated dissociation included structural and functional brain alterations in regions that have previously been implicated in FND, such as the anterior cingulate cortex.ConclusionsDissociative symptoms and disorders are common in FND, and different FND subgroups appear to endorse varying degrees of psychoform or somatoform dissociation. Presence of dissociative symptoms in FND is associated with adverse clinical features; there is therefore a clinical need to assess patients with FND for dissociative symptomatology and to address these symptoms during treatment. Future research should examine dissociation further in different FND subgroups, using measures that distinguish between different types of dissociation, alongside measures of underlying pathophysiology.

Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysms of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite this importance, there remains little agreement – and frequent debate – on what to call this condition, known inter alia as psychogenic non-epileptic seizures (PNES), dissociative seizures (DS), functional seizures (FS), non-epileptic attack disorder (NEAD), pseudoseizures, conversion disorder with seizures, and by many other labels besides. This choice of terminology is not merely academic – it affects patients’ response to and understanding of their diagnosis, and their ability to navigate health care systems.This paper summarises two recent discussions hosted by the American Epilepsy Society and Functional Neurological Disorders Society on the naming of this condition. These discussions are conceptualised as the initial step of an exploration of whether it might be possible to build consensus for a new diagnostic label.

Background Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. Objectives To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive–behavioural therapy for adults with dissociative seizures. Design This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. Setting This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive–behavioural therapy services. Participants Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. Interventions Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive–behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. Main outcome measures The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. Results In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive–behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1–35 dissociative seizures); cognitive–behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0–20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive–behavioural therapy at a p-value p-value ≤ 0.001: the longest dissociative seizure-free period in months 7–12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect –0.39, 95% confidence interval –0.61 to –0.18; p p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p p Limitations Unlike outcome assessors, participants and clinicians were not blinded to the interventions. Conclusions There was no significant additional benefit of dissociative seizure-specific cognitive–behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive–behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive–behavioural therapy. Future work Examination of moderators and mediators of outcome. Trial registration Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.

Background\ud \ud The PHQ-9 is a self-administered depression screening instrument. Little is known about its utility and accuracy in detecting depression in adults with dissociative seizures (DS).\ud \ud \ud Objectives\ud \ud Using the Mini – International Neuropsychiatric Interview as a reference, we evaluated the diagnostic accuracy of the PHQ-9 in adults with DS, examined its convergent and discriminant validity and uniformity.\ud \ud \ud Methods\ud \ud Our sample comprised 368 people with DS who completed the pre-randomisation assessment of the CODES trial. The uniformity of the PHQ-9 was determined using factor analysis for categorical data. Optimal cut-offs were determined using the area under the curve (AUC), Youden Index, and diagnostic odds ratio (DOR). Convergent and discriminant validity were assessed against pre-randomisation measures.\ud \ud \ud Results\ud \ud Internal consistency of the PHQ-9 was high (α = 0.87). While the diagnostic odds ratio suggested that a cut-off of ≥10 had the best predictive performance (DOR = 14.7), specificity at this cut off was only 0.49. AUC (0.74) and Youden Index (0.48) suggested a ≥ 13 cut-off would yield an optimal sensitivity (0.81) and specificity (0.67) balance. However, a cut-off score of ≥20 would be required to match specificity resulting from a cut-off of ≥13 in other medical conditions. We found good convergent and discriminant validity and one main factor for the PHQ-9.\ud \ud \ud Conclusions\ud \ud In terms of internal consistency and structure, our findings were consistent with previous validation studies but indicated that a higher cut-off would be required to identify DS patients with depression with similar specificity achieved with PHQ-9 screening in different clinical and non-clinical populations.

Highlights • Evidence-based guidelines use systematic reviews to support clinical recommendations. • Adherence to evidence-based guidelines improves healthcare costs and patient outcomes. • Recent randomized trials make guidelines for functional neurological disorders possible., Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.

Background Nested within a large, multicenter randomized controlled trial (RCT) for people with dissociative seizures (DS), the study used purposive sampling to explore participants' experience of participating in an RCT, their experience of DS-specific cognitive behavioral therapy (CBT) and another component of the RCT, Standardized Medical Care (SMC) and their perceptions of and reflections on seizure management and change. Methods A qualitative study using semistructured interviews was conducted with 30 participants in an RCT (the COgnitive behavioral therapy vs standardized medical care for adults with Dissociative non-Epileptic Seizures (CODES) Trial) investigating the effectiveness of two treatments for DS. Key themes and subthemes were identified using thematic framework analysis (TFA). Results Analysis yielded three overarching themes: taking part in a treatment trial — “the only thing out there”, the experience of treatment techniques that were perceived to help with seizure management, and reflections on an “unpredictable recovery”. Conclusions People with DS are amenable to participating in a psychotherapy RCT and described a largely positive experience. They also described the applicability of aspects of DS-specific CBT and SMC in the management of their DS, received within the confines of the CODES trial. Factors that appeared to account for the variability in response to treatment delivery included individual preferences for the nature of sessions, the nature of therapeutic relationships, readiness to discuss trauma, other aspects of emotional avoidance, and whether therapy provided something new., Highlights • Participants generally perceived participating in an RCT as a positive experience. • Participants perceived that the CODES RCT offered them the possibility of change. • Breathing and distraction techniques were perceived to help with seizure management. • Participants identified the importance of a good therapeutic alliance. • Seizure control or acceptance of ongoing seizures was perceived as progress.

Objectives Little is known about the experiences of therapists delivering psychotherapy for patients with dissociative seizures (DS), a complex disorder associated with a range of comorbid psychosocial and mental health difficulties. This study set out to explore therapists' experiences of delivering DS-specific, manualized cognitive behavioral therapy (CBT) to adults with DS within the context of a randomized control trial. Methods Interviews were conducted with 12 therapists involved in the COgnitive behavioral therapy vs standardized medical care for adults with Dissociative non-Epileptic Seizures (CODES) trial and were analyzed using thematic framework analysis (TFA). Results Six main themes emerged, namely 1) aspects of the intervention that were favored, while others were not always considered applicable; 2) multiple and complex difficulties faced by patients; 3) working effectively within the protocol; 4) limitations of the protocol; 5) significance of formulation; and 6) quality of standardized medical care (SMC) and difficulties of diagnosis delivery. These addressed valued aspects of the intervention, complexities of the patient group, and experiences working within a structured treatment protocol. Family involvement and psychoeducation were highlighted as important components; the applicability of graded exposure techniques, however, was restricted by patients' apparent emotional avoidance. The structure provided by the treatment protocol was valued, but flexibility was important to individualize treatment in complex cases. A comprehensive formulation was fundamental to this. The initial diagnostic explanation provided by neurologists and psychiatrists was generally considered beneficial, with patients often perceived to enter therapy with a better understanding of their condition. Conclusions This study demonstrated that the DS-specific CBT intervention met with general approval from therapists who also highlighted some practical challenges. Because of the nature of the condition, the need for experience of working with complex patients should be considered when applying the intervention to individual cases. Setting the CBT intervention in the context of a structured care pathway involving neurology and psychiatry may facilitate the therapeutic process., Highlights • Therapists can use DS-specific CBT with patients with DS, despite challenges. • Clinical experience and understanding patients' complexity are important. • Clinical formulation is an important aspect of this DS-specific CBT. • Flexibility in ordering treatment components of this manualized therapy is important.

ObjectivesWe aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes.MethodsA systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group.ResultsFive FND-specific measures were identified—three clinician-rated and two patient-rated—but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost–utility (eg, healthcare resource use and quality-adjusted life years).ConclusionsThere are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population.

Introduction: We aimed to examine susceptibility to dissociation and the impact of dissociation on interoceptive processing in individuals with functional neurological disorder (FND). We hypothesised that dissociative states would be elevated and interoceptive accuracy and awareness impaired at baseline in people with FND, and that such differences would be exacerbated following acute dissociation. Methods: Nineteen adults with FND were compared to 20 healthy controls. A modified heart-beat tracking task measured interoceptive accuracy and awareness (confidence) before and after a validated dissociation induction procedure. An exteroceptive processing control task was included. Mann–Whitney tests and r-values (effect size) were computed for between-group comparisons. Results: The FND group displayed elevated dissociation at baseline (p = 0.001, r = 0.528) compared to controls which increased following dissociation-induction (p r = 0.663). Interoceptive accuracy did not differ between groups at baseline (p = 0.967, r = 0.009); however, the FND group had lower accuracy scores post-induction (p = 0.021, r = 0.379). A negative correlation (trend) between change scores for dissociation and interoceptive accuracy was noted (rs = −0.411, p = 0.057). Confidence ratings on interoceptive and exteroceptive processing tasks were lower in the FND group (p-values r-values 0.331–0.489). Conclusions: Individuals with FND experienced greater susceptibility to dissociation, metacognitive deficits and impaired interoceptive accuracy than controls after acute dissociation.

The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.

Purpose: Patients with dissociative (non-epileptic) seizures typically receive their diagnosis from neurologists, but are often referred to psychiatrists, whom they may be reluctant to go and see. We aimed to assess which factors were associated with first attendance at psychiatric services. Methods: A cohort study of 698 participants involved in the pre-randomisation phase of the CODES trial, a randomised controlled trial assessing the benefit of cognitive behavioural therapy for dissociative seizures when added to standardised medical (including psychiatric) care. Patients diagnosed by neurologists from 27 UK centres provided demographic information and a measure of diagnostic confidence. Neurologists described predominant seizure type and comorbidity with epilepsy. We analysed hypothesised (young age, male, residing in areas of higher deprivation, low belief in diagnosis) and exploratory factors for their association with first attendance with the psychiatrist about 3 months later.Results: 568/698 (81.4%) participants attended a psychiatry appointment. None of the following were associated with attendance: Location, age, gender, deprivation score, relationship status, ethnicity, level of education, employment status, receipt of disability benefits, duration, previous diagnosis of epilepsy or mental health problems and degree of confidence in the diagnosis. The only variable differing between groups was having a carer (21.5% not attending vs 38.6% attending).Conclusion: First attendance at a psychiatry appointment after a neurologist had given a diagnosis of dissociative seizures was not associated with any hypothesised predictors, including patient confidence in the diagnosis. Neurologists should put aside any expectations about these variables when referring to and anticipating attendance with a psychiatrist.

Background\ud Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency.\ud \ud Methods\ud In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544.\ud \ud Findings\ud Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0–20] in the CBT plus standardised medical care group vs 7 seizures [1–35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56–1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference −0·53 [95% CI −0·97 to −0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference −4·12 [95% CI −6·35 to −1·89]; p

OBJECTIVE Given the significant impact epilepsy can have on health-related quality of life (HRQoL) of individuals with this condition and their families, there is great clinical interest in evidence-based psychological treatments aimed at enhancing well-being in people with epilepsy (PWE). An evaluation of the current evidence is needed to assess the effects of psychological treatments for PWE on HRQoL outcomes to inform future therapeutic recommendations and research designs. METHODS The operational definition of psychological treatments included a broad range of interventions that use psychological or behavioral techniques designed to improve HRQoL, psychiatric comorbidities, and seizure frequency and severity for adults and children with epilepsy. A systematic literature search was conducted in line with Cochrane criteria for randomized controlled trials (RCTs) and quasi-RCTs investigating psychological treatments and using HRQoL outcome measures as primary or secondary outcome measures. Standard methodological procedures required by the Cochrane Collaboration were used for data collection and analysis. RESULTS Twenty-four completed RCTs were included in this review (2439 participants). Based on satisfactory methodological homogeneity, data from 9 studies (468 participants) providing Quality of Life in Epilepsy-31 (QOLIE-31) outcomes were pooled for meta-analyses, showing significant mean changes for QOLIE-31 total score and 6 subscales. The significant mean changes of QOLIE-31 total score (mean improvement of 5.68 points; 95% confidence interval = 3.11-8.24, P

Objectives/AimsAmyotrophic Lateral Sclerosis (ALS), also known as Motor Neuron Disease (MND), is a progressive and life-limiting neurodegenerative disease which can involve behavioural change. There are five commonly reported disease-specific screening tools of behavioural change but it is not clear how they differ in applicability. This study therefore set out to investigate the extent to which these measures similarly identify impairment by examining i) intercorrelations between scores on the measures completed about the same people with ALS, and ii) the percentage of people with ALS characterised as impaired on each measure.MethodsThe behavioural component of the ALS-Cognitive Behavioural Screen (ALS-CBS-b), behavioural component of the Edinburgh Cognitive and Behavioural ALS Screen (ECAS-b), ALS-Frontotemporal Dementia Questionnaire (ALS-FTD-Q), Beaumont Behavioural Inventory (BBI), and MND Behavioural Instrument (MiND-B) were all completed by 35 carers of people with ALS. Total scores for each measure underwent Spearman correlation analysis. Classifications of impairment (for behavioural impairment or ALS-FTD) were determined using published cut-offs and agreement between measures was determined by calculating Cohens kappa coefficients.ResultsThe behavioural measures were significantly intercorrelated (pConclusionsExisting measures of behavioural change in people with ALS may yield very differing conclusions and cannot be assumed to be interchangeable. Variability in the detection of impairment between measures may result from differing item content, behaviours sampled or cut-off scores for impairment. This inconsistency between measures may lead to inappropriate healthcare provision and discrepancies in research conclusions.FundingMND Association

Objective It has been debated whether different stages in the human sleep cycle preferentially mediate the consolidation of explicit and implicit memories, or whether all of the stages in succession are necessary for optimal consolidation. Here we investigated whether the selective deprivation of slow wave sleep (SWS) or rapid eye movement (REM) sleep over an entire night would have a specific effect on consolidation in explicit and implicit memory tasks. Method Participants completed a set of explicit and implicit memory tasks at night, prior to sleep. They had 1 control night of undisturbed sleep and 2 experimental nights, during which either SWS or REM sleep was selectively deprived across the entire night (sleep conditions counterbalanced across participants). Polysomnography recordings quantified precisely the amount of SWS and REM sleep that occurred during each of the sleep conditions, and spindle counts were recorded. In the morning, participants completed the experimental tasks in the same sequence as the night before. Results SWS deprivation disrupted the consolidation of explicit memories for visuospatial information (ηp2 = .23), and both SWS (ηp2 = .53) and REM sleep (ηp2 = .52) deprivation adversely affected explicit verbal recall. Neither SWS nor REM sleep deprivation affected aspects of short-term or working memory, and did not affect measures of verbal implicit memory. Spindle counts did not correlate significantly with memory performance. Conclusions These findings demonstrate the importance of measuring the sleep cycles throughout the entire night, and the contribution of both SWS and REM sleep to memory consolidation. (PsycINFO Database Record

Background: There is a lack of knowledge about what factors may impede or facilitate engagement in psychological interventions in people with motor neuron disease (pwMND) and how such interventions can be adapted to best meet the needs of this population. Objectives: To explore the needs and preferences of pwMND with respect to psychological interventions, and how best to adapt such interventions for pwMND. Methods: A series of semi-structured interviews (n = 22) and workshops (n = 3) were conducted with pwMND (n = 15), informal caregivers of pwMND (n = 10), and MND healthcare professionals (n = 12). These explored preferences and concerns that would need to be considered when delivering a psychological intervention for pwMND. Three areas were explored: (i) perceived factors that may hinder or facilitate pwMND engaging with psychological interventions; (ii) ways in which such interventions could be adapted to meet the individual needs of pwMND; and (iii) views regarding the main psychological issues that would need to be addressed. Workshops and interviews were audio recorded and transcribed and thematic analysis was used to inductively derive themes. Findings: Data could be classified within four overarching themes: unfamiliar territory; a series of losses; variability and difficulty meeting individual needs; and informal support. Conclusions: Flexibility, tailoring interventions to the individual needs of pwMND, and encouraging autonomy are key attributes for psychological interventions with pwMND. Psychological interventions such as Acceptance and Commitment Therapy (ACT) could be acceptable for pwMND if adapted to their specific needs.

Purpose: We investigated neurologists’ experience of participating in the large CODES trial involving around 900 adults with dissociative seizures which subsequently evaluated the effectiveness of tailored cognitive behavioural therapy (CBT) plus standardised medical care versus standardised medical care alone in 368 patients with dissociative seizures.Method: We asked all neurologists referring patients with dissociative seizures to the CODES study to complete a 43-item online survey. This examined neurologists’ (i) demographics, (ii) knowledge of dissociative seizures before and after their involvement in the CODES trial, (iii) clinical practice before, during and since their involvement, and (iv) their experience of the CODES trial. Results: Forty-three (51%) neurologists completed the questionnaire. Only about half of neurologists could make referrals to psychological intervention specific for dissociative seizures before and after the trial. One-third of doctors reported having changed their referral practice following their involvement. The majority (>69%) agreed that patient satisfaction with different aspects of the trial was very high, and 83.7% thought that it was easy to recruit patients for the study. Over 90% agreed they would like the treatment pathway to continue. Respondents found different elements of the trial useful, in particular, the patient factsheet booklet (98%), diagnosis communication advice (93%) and the CBT package (93%).Conclusions: Neurologists participating in CODES generally found it easy to recruit patients and perceived patient satisfaction as very high. However, 46.5% of neurologists could not offer psychotherapy once the trial had finished; suggesting that problems with lack of access to psychological treatment for dissociative seizures persist.

Objective: Cognitive and behavioural change in Amyotrophic Lateral Sclerosis (ALS) is well accepted. Several screening tools have been developed to detect such changes. Further guidance on their use may come from a consideration of the rigour with which they were validated. This systematic review set out to critically appraise and present published data pertaining to the validation of six screening tools used to diagnose cognitive and/or behavioural change in patients with ALS. Methods: The screening tools considered in this search included: The Edinburgh Cognitive and Behavioural ALS Screen (ECAS), The ALS Cognitive Behavioural Screen (ALS-CBS), The Motor Neurone Disease Behavioural Scale (MiND-B), The Frontal Behavioural Inventory ALS Version, The ALS Frontotemporal Dementia Questionnaire (ALS-FTD-Q) and The Beaumont Behavioural Inventory (BBI). MEDLINE, EMBASE and PsycINFO were searched until 4th week of June 2017. Results: Fourteen eligible studies were included in the review. Papers either reported data concerning convergent validity or clinical validity. Validation data concerning the ECAS showed this screening tool to have strong clinical validity, although further work needs to consider how its use will affect diagnosis rates according to current diagnostic guidelines. When screening for behavioural change only, more limited information is available; the BBI may offer greater potential than the ALS-FTD-Q for detecting mild impairment as it assesses a wider range of behavioural changes. Conclusions: Scores of sensitivity, specificity, positive predictive values and negative predictive values should be given considerable importance when considering which screening tools to incorporate into current clinical practice.

BACKGROUND:\ud\udDespite its potentially significant impact, cognitive disability may be overlooked in a number of progressive neurodegenerative conditions, as other difficulties dominate the clinical picture.\ud\ud\udOBJECTIVE:\ud\udWe examined the extent, nature and range of the research evidence relating to cognitive rehabilitation, self-management, psychotherapeutic and caregiver support interventions in Parkinsonian disorders, multiple sclerosis (MS), frontotemporal dementias (FTD), motor neuron disease and Huntington’s disease.\ud\ud\udMETHODS:\ud\udScoping review based on searches of MEDLINE and CINAHL up to 15 March 2016.\ud\ud\udRESULTS:\ud\udWe included 140 eligible papers. Over half of the studies, and almost all the randomised controlled trials, related to MS, while a number of single case studies described interventions for people with FTD. CR interventions addressed functional ability, communication and interaction, behaviour or memory. The majority of psychotherapy interventions involved cognitive behavioural therapy for depression or anxiety. Self-management interventions were mainly available for people with MS. There were few reports of interventions specific to caregivers. Numerous methodological challenges were identified.\ud\ud\udCONCLUSIONS:\ud\udThe limited range of studies for all conditions except MS suggests a need firstly to synthesise systematically the available evidence across conditions and secondly to develop well-designed studies to provide evidence about the effectiveness of CR and other psychological interventions.

Functional neurological disorder (FND) is a common and highly disabling disorder, but its aetiology remains enigmatic. Conceptually, there has been reduced emphasis on the role of psychosocial stressors in recent years, with a corresponding increase in neurobiological explanations. However, a wealth of evidence supports the role of psychosocial adversities (eg, stressful life events, interpersonal difficulties) as important risk factors for FND. Therefore, there is a need to integrate psychosocial (environmental) and neurobiological factors (eg, sensorimotor and cognitive functions) in contemporary models of FND. Altered emotional processing may represent a key link between psychosocial risk factors and core features of FND. Here, we summarise and critically appraise experimental studies of emotional processing in FND using behavioural, psychophysiological and/or neuroimaging measures in conjunction with affective processing tasks. We propose that enhanced preconscious (implicit) processing of emotionally salient stimuli, associated with elevated limbic reactivity (eg, amygdala), may contribute to the initiation of basic affective/defensive responses via hypothalamic and brainstem pathways (eg, periaqueductal grey). In parallel, affect-related brain areas may simultaneously exert a disruptive influence on neurocircuits involved in voluntary motor control, awareness and emotional regulation (eg, sensorimotor, salience, central executive networks). Limbic-paralimbic disturbances in patients with FND may represent one of several neurobiological adaptations linked to early, severe and/or prolonged psychosocial adversity. This perspective integrates neurobiological and psychosocial factors in FND and proposes a research agenda, highlighting the need for replication of existing findings, multimodal sampling across emotional response domains and further examination of emotional influences on sensorimotor and cognitive functions in FND populations.

Objective There have, as yet, been few experimental studies of explicit facial affect recognition in patients with dissociative seizures (DS). The aim of the study was to examine explicit recognition and physiological responses to facial expressions in this group, relative to healthy controls. Methods Forty patients with DS and 43 controls completed a computerized test of facial affect recognition, including five basic expressions (happiness, anger, disgust, fear, neutral). Recognition accuracy, emotional intensity judgements, and skin conductance levels and responses were dependent measures. Analyses controlled for a range of potentially confounding variables, including anxiety, depression, and medication effects. Results The DS group was less accurate at identifying facial expressions than controls (p = .005, ηp = 0.10). No group difference emerged for intensity judgements (p = .72, ηp = 0.002). Mean skin conductance levels were higher in the DS group relative to controls (p = .046, ηp = 0.053). However, a subgroup of DS patients showed attenuated skin conductance responses to the facial stimuli, compared with controls (p = .015, ηp = 0.18). These differences could not be accounted for by possible confounding variables. Recognition accuracy for neutral faces correlated negatively with trauma scores (r = -0.486, p = .002) and abandonment concerns (r = -0.493, p = .002) in the DS group. Conclusions Patients with DS showed reduced recognition accuracy for facial affect, despite accurately perceiving its intensity. Elevated autonomic arousal may characterize patients with DS in general, alongside reduced phasic autonomic responses to facial expressions in some patients with the disorder.

Summary Objective Epilepsy is one of the most common neurological conditions affecting about 1% of adults. Up to 40% of people with epilepsy (PWE) report recurring seizures while on medication. And optimal functioning requires good self‐management. Our objective was to evaluate a group self‐management education courses for people with epilepsy and drug‐resistant seizures by means of a multicenter, pragmatic, parallel group, randomized controlled trial. Methods We recruited adults with epilepsy, having ≥2 seizures in the prior 12 months, from specialist clinics. Consenting participants were randomized 1:1 to a group course or treatment as usual. The primary outcome measure was quality of life 12 months after randomization using Quality of Life 31‐P (QOLIE‐31‐P). Secondary outcome measures were seizure frequency and recency, psychological distress, impact and stigma of epilepsy, self‐mastery, medication adherence, and adverse effects. Analysis of outcomes followed the intention‐to‐treat principle using mixed‐effects regression models. Results We enrolled 404 participants (intervention: n = 205, control: n = 199) with 331 (82%) completing 12‐month follow‐up (intervention: n = 163, control: n = 168). Mean age was 41.7 years, ranging from 16 to 85, 54% were female and 75% were white. From the intervention arm, 73.7% attended all or some of the course. At 12‐month follow‐up, there were no statistically significant differences between trial arms in QOLIE‐31‐P (intervention mean: 67.4, standard deviation [SD]: 13.5; control mean: 69.5, SD 14.8) or in secondary outcome measures. Significance This is the first pragmatic trial of group education for people with poorly controlled epilepsy. Recruitment, course attendance, and follow‐up rates were higher than expected. The results show that the primary outcome and quality of life did not differ between the trial arms after 12 months. We found a high prevalence of felt‐stigma and psychological distress in this group of people with drug‐resistant seizures. To address this, social and psychological interventions require evaluation, and may be necessary before or alongside self‐management‐education courses.

Importance: Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes. Observations: Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited. Conclusions and Relevance: Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.

Given the significant impact that psychosocial factors and epilepsy treatments can have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is great clinical interest in the role of psychological evaluation and treatments to improve HRQOL and comorbidities. Therefore, the International League Against Epilepsy (ILAE) charged the Psychology Task Force with the development of recommendations for clinical care based on evaluation of the evidence from their recent Cochrane review of psychological treatments in individuals with epilepsy. The literature search for a recent Cochrane review of randomized controlled trials investigating psychological treatments for individuals with epilepsy constitutes the key source of evidence for this article. To provide practical guidance to service providers, we provide ratings on study research designs based on (1) the American Academy of Neurology's Level of Evidence system and (2) the Grading of Recommendations, Assessment, Development, and Evaluation system. This paper is the culmination of an international collaboration process involving pediatric and adult psychologists, neurologists, psychiatrists, and neuropsychiatrists. The process and conclusions were reviewed and approved by the ILAE Executive Committee. The strongest evidence for psychological interventions was identified for the most common mental health problems, including depression, neurocognitive disturbances, and medication adherence. Psychological interventions targeting the enhancement of HRQOL and adherence and a decrease in comorbidity symptoms (anxiety, depression) should be incorporated into comprehensive epilepsy care. There is a range of psychological strategies (ie, cognitive behavioral therapy and mindfulness-based therapies) that show promise for improving the lives of persons with epilepsy, and clinical recommendations are provided to assist epilepsy health care providers in treating the comorbidities and challenges associated with epilepsy and its treatments.

BackgroundEpilepsy is a common neurological condition resulting in recurrent seizures. Research evidence in long-term conditions suggests that patients benefit from self-management education and that this may improve quality of life (QoL). Epilepsy self-management education has yet to be tested in a UK setting.ObjectivesTo determine the effectiveness and cost-effectiveness of Self-Management education for people with poorly controlled epILEpsy [SMILE (UK)].DesignA parallel pragmatic randomised controlled trial.SettingParticipants were recruited from eight hospitals in London and south-east England.ParticipantsAdults aged ≥ 16 years with epilepsy and two or more epileptic seizures in the past year, who were currently being prescribed antiepileptic drugs.InterventionA 2-day group self-management course alongside treatment as usual (TAU). The control group received TAU.Main outcome measuresThe primary outcome is QoL in people with epilepsy at 12-month follow-up using the Quality Of Life In Epilepsy 31-P (QOLIE-31-P) scale. Other outcomes were seizure control, impact of epilepsy, medication adverse effects, psychological distress, perceived stigma, self-mastery and medication adherence. Cost-effectiveness analyses and a process evaluation were undertaken.RandomisationA 1 : 1 ratio between trial arms using fixed block sizes of two.BlindingParticipants were not blinded to their group allocation because of the nature of the study. Researchers involved in data collection and analysis remained blinded throughout.ResultsThe trial completed successfully. A total of 404 participants were enrolled in the study [SMILE (UK),n = 205; TAU,n = 199] with 331 completing the final follow-up at 12 months [SMILE (UK),n = 163; TAU,n = 168]. In the intervention group, 61.5% completed all sessions of the course. No adverse events were found to be related to the intervention. At baseline, participants had a mean age of 41.7 years [standard deviation (SD) 14.1 years], and had epilepsy for a median of 18 years. The mean QOLIE-31-P score for the whole group at baseline was 66.0 out of 100.0 (SD 14.2). Clinically relevant levels of anxiety symptoms were reported in 53.6% of the group and depression symptoms in 28.0%. The results following an intention-to-treat analysis showed no change in any measures at the 12-month follow-up [QOLIE-31-P: SMILE (UK) mean: 67.4, SD 13.5; TAU mean: 69.5, SD 14.8]. The cost-effectiveness study showed that SMILE (UK) was possibly cost-effective but was also associated with lower QoL. The process evaluation with 20 participants revealed that a group course increased confidence by sharing with others and improved self-management behaviours.ConclusionsFor people with epilepsy and persistent seizures, a 2-day self-management education course is cost-saving, but does not improve QoL after 12-months or reduce anxiety or depression symptoms. A psychological intervention may help with anxiety and depression. Interviewed participants reported attending a group course increased their confidence and helped them improve their self-management.Future workMore research is needed on self-management courses, with psychological components and integration with routine monitoring.Trial registrationCurrent Controlled Trials ISRCTN57937389.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 22, No. 21. See the NIHR Journals Library website for further project information.

This study sought to extend knowledge about the previously reported preconscious attentional bias (AB) for facial emotion in patients with dissociative seizures (DS) by exploring whether the finding could be replicated, while controlling for concurrent anxiety, depression, and potentially relevant cognitive impairments. Patients diagnosed with DS (n=38) were compared with healthy controls (n=43) on a pictorial emotional Stroop test, in which backwardly masked emotional faces (angry, happy, neutral) were processed implicitly. The group with DS displayed a significantly greater AB to facial emotion relative to controls; however, the bias was not specific to negative or positive emotions. The group effect could not be explained by performance on standardized cognitive tests or self-reported depression/anxiety. The study provides additional evidence of a disproportionate and automatic allocation of attention to facial affect in patients with DS, including both positive and negative facial expressions. Such a tendency could act as a predisposing factor for developing DS initially, or may contribute to triggering individuals' seizures on an ongoing basis. Psychological interventions such as Cognitive Behavioral Therapy (CBT) or AB modification might be suitable approaches to target this bias in clinical practice.

This chapter, of particular interest to those interested in psychological treatments for people with amyotrophic lateral sclerosis (ALS), outlines earlier work that sought to identify correlates of reduced well-being and quality of life in people with ALS and delineates possible targets for intervention. In this context, the chapter then evaluates several studies that have investigated psychological interventions for optimizing well-being in people with ALS and their caregivers. The chapter reviews current efforts to address the paucity of interventional research in this patient group, focusing on five therapies that have so far been evaluated for treatment efficacy. These therapies include hypnosis, mindfulness, cognitive behavioural therapy, expressive disclosure therapy, and dignity therapy. The main findings from these studies and their clinical implications for people with ALS and their families are discussed. Recommendations for future research are considered, together with a discussion of the implementation of such interventions in therapeutic or multidisciplinary settings.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder of the motor system with recognised extra-motor and cognitive involvement. This cross-sectional study examined ALS patients' performance on measures requiring social inference, and determined the relationship between such changes and variations in mood, behaviour, personality, empathy and executive function. Fifty-five ALS patients and 49 healthy controls were compared on tasks measuring social cognition and executive function. ALS patients also completed measures examining mood, behaviour and personality. Regression analyses explored the contribution of executive function, mood, behaviour and personality to social cognition scores within the ALS sample. A between-group MANOVA revealed that, the ALS group was impaired relative to controls on two composite scores for social cognition and executive function. Patients also performed worse on individual tests of executive function measuring cognitive flexibility, response inhibition and concept formation, and on individual aspects of social cognition assessing the attribution of emotional and mental states. Regression analyses indicated that ALS-related executive dysfunction was the main predictor of social cognition performance, above and beyond demographic variables, behaviour, mood and personality. On at least some aspects of social cognition, impaired performance in ALS appears to be secondary to executive dysfunction. The profile of cognitive impairment in ALS supports a cognitive continuum between ALS and frontotemporal dementia.