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Functional status (FSt) describes the phenomenon of prolonged non-epileptic attacks that may be misidentified as Status Epilepticus (SE). The early differentiation between epileptic and functional status is crucial in order to avoid unnecessarily invasive and costly medical escalation in the latter group, including the hazards of overmedication, intubation and intensive care admission. The authors conducted a literature review of available studies describing cases of functional status to extract the common aspects of FSt seizure semiology, investigations used to differentiate from SE, and guidance for managing FSt. A search was carried out using Medline, Embase and PsychInfo databases and 3909 papers were extracted for review. 30 papers were found relevant for inclusion, describing 260 cases of FSt. FSt was found to occur more commonly in younger, female patients with a family history of epilepsy, co-morbid psychiatric diagnosis and following a recent traumatic event. Common clinical features of FSt during and after, the events were identified. While video-EEG remains the gold standard investigation for differentiating FSt from SE, many of the included studies considered the utility of other investigation modalities including serum markers and neuroimaging. One key shortcoming identified within the literature reviewed was a lack of well-defined guidance on the acute management of FSt. We offer an A-F step management plan for the immediate and longer term assessment and treatment of FSt.

BACKGROUND: Functional seizures (FS), otherwise known as psychogenic nonepileptic seizures (PNES), are a common symptom presenting to neurology and epilepsy clinics. There is a pressing need for further research to understand the neurobiology of FS to develop mechanistically targeted treatments. Joint hypermobility is an expression of variation in connective tissue structure along a spectrum, and it has received increasing attention in functional neurological disorders, but there is lack of evidence of its relevance in FS. METHODS: In the present study, forty-two patients with FS and a non-clinical comparison group of 34 age/sex-matched controls were recruited. Joint hypermobility of all participants was quantified using the Beighton scale. RESULTS: In our sample, 24 (57%) patients with FS, and 7 (21%) of the comparison group met criteria for joint hypermobility (p = 0.002). Our statistical model revealed that patients with FS showed a significant degree of hypermobility compared to the comparison group (odds ratio = 11.1; Confidence interval: 2.1-78.0, p = 0.008), even after controlling age, sex, anxiety, and depression. CONCLUSION: We found a significant association between FS and joint hypermobility, which was independent of anxiety and depression.

We describe a patient who presented with gender identity dysphoria and stroke-like symptoms who we diagnosed with Munchausen's syndrome (factitious disorder). We discuss whether a brain lesion in the left frontal cortex is a possible risk factor, and support this hypothesis through neuropsychological investigation, EEG abnormalities, and a personality assessment. This case report supports previous suggestions that underlying brain disease/lesions might be risk factors for Munchausen's syndrome (factitious disorder).

Many examinations are now delivered online using digital formats, the migration to which has been accelerated by the COVID-19 pandemic. The MRCPsych theory examinations have been delivered in this way since Autumn 2020. The multiple choice question formats currently in use are highly reliable, but other formats enabled by the digital platform, such as very short answer questions (VSAQs), may promote deeper learning. Trainees often ask for a focus on core knowledge, and the absence of cueing with VSAQs could help achieve this. This paper describes the background and evidence base for VSAQs, and how they might be introduced. Any new question formats would be thoroughly piloted before appearing in the examinations and are likely to have a phased introduction alongside existing formats.

Depression is the most common, though often under-recognised, neuropsychiatric disturbance in movement disorders (MD). This study aimed to establish whether a briefer screening measure such as a visual analogue screening measure (Emotions Thermometer) or Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) could be a potentially suitable screening tool for depression in MD patients. Patients attending a regional MD outpatient clinic completed the Emotional Thermometer 7-item tool (ET7), the Hospital Anxiety and Depression Scale (HADS) and the Neurological Disorders Depression Inventory for Epilepsy (NDDIE). We used the Major Depression Inventory which provided the diagnosis of depression based on ICD-10 and DSM-IV as our diagnostic gold standard to compare the performance of ET7 and its individual sub-scales, its briefer version ET4, HADS, and NDDIE. Sensitivity, specificity, positive predictive value, negative predictive value and receiver operating characteristic curves were calculated to compare the performance of the screening tools. In total, 188 patients were included in the analysis. The most accurate tools as determined by Receiver Operating Characteristics curve were HADS-D for ICD-10 depressive episode and DepT for DSM-IV major depression. ET4 performed well as a ‘rule-out’ screening tool for both DSM-IV and ICD-10 depression. ET4 performance was comparable to HADS without the need for clinician scoring. The briefer ET4 performed almost as well as ET7. Emotions Thermometer and NDDI-E are quick and reliable screening tools for depression in the MD population and are comparable to HADS. We suggest routine use of visual analogue ET4 as it is briefer, requires less time to complete and does not require scoring from the clinicians. It has the potential to be widely implemented across busy neurology clinics to assist in depression screening.

Objective\ud Dissociative traits represent a disturbance in selfhood that may predispose to, and trigger, functional seizures (FSs). The predictive representation and control of the internal physiological state of the body (interoception) are proposed to underpin the integrity of the sense of self (“minimal selfhood”). Therefore, discrepancies between objective and subjective aspects of interoception may relate to symptom expression in patients with FSs. Here, we tested whether individual differences in trait measures of interoception relate to dissociative symptoms, and whether state interoceptive deficits predict FS occurrence.\ud \ud Methods\ud Forty‐one participants with FSs and 30 controls completed questionnaire ratings of dissociation, and measures of (1) interoceptive accuracy (IA)—objective performance on heartbeat detection tasks; (2) trait interoceptive sensibility—subjective sensitivity to internal sensations (using the Porges Body Perception Questionnaire); and (3) state interoceptive sensibility—subjective trial‐by‐trial measures of confidence in heartbeat detection. Interoceptive trait prediction error (ITPE) was calculated from the discrepancy between IA and trait sensibility, and interoceptive state prediction error (ISPE) from the discrepancy between IA and state sensibility.\ud \ud Results\ud Patients with FSs had significantly lower IA and greater trait interoceptive sensibility than healthy controls. ITPE was the strongest predictor of dissociation after controlling for trait anxiety and depression in a regression model. ISPE correlated significantly with FS frequency after controlling for state anxiety.\ud \ud Significance\ud Patients with FSs have disturbances in interoceptive processing that predict both dissociative traits reflecting the disrupted integrity of self‐representation, and the expression of FSs. These findings provide insight into the pathophysiology of functional neurological disorder, and could lead to novel diagnostic and therapeutic approaches.

Functional seizures are a common neurological presentation but access to evidence-based treatments is sporadic and often delayed. Patient engagement is an essential prerequisite to any treatment benefits, but previous research has not investigated engagement with psychological group treatments. In this service evaluation, we compared patients who initially engaged and disengaged from an online CBT-based group treatment on demographic and clinical variables, and illness-related beliefs. A self-report survey was used to explore reasons for disengagement. Of 64 patients invited to the group treatment, 39 (60.1%) disengaged before the first session. Older age was associated with engagement with the functional seizures group. There were no other group differences between demographic, clinical, or belief-based variables. Patients who disengaged reported the timing and format as barriers to joining and had preferences for individual and in-person interventions. These findings have implications for the role of clinicians in providing regular tangible information about referral pathways, and motivating patients to engage with available treatments.

ObjectiveDepression is a common, serious, but under-recognised problem in multiple sclerosis (MS). The primary objective of this study was to assess whether a rapid visual analogue screening tool for depression could operate as a quick and reliable screening method for depression, in patients with MS.MethodPatients attending a regional MS outpatient clinic completed the Emotional Thermometer 7 tool (ET7), the Hospital Anxiety and Depression Scale – Depression Subscale (HADS-D) and the Major Depression Inventory (MDI) to establish a Diagnostic and Statistical Manual, 4th edition (DSM-IV) diagnosis of Major Depression. Full ET7, briefer subset ET4 version and depression and distress thermometers alone were compared with HADS-D and MDI. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and receiver operating characteristic (ROC) curve were calculated to compare the performance of all the screening tools.ResultsIn total, 190 patients were included. ET4 performed well as a ‘rule-out’ screening step (sensitivity 0.91, specificity 0.72, NPV 0.98, PPV 0.32). ET4 performance was comparable to HADS-D (sensitivity 0.96, specificity 0.77, NPV 0.99, PPV 0.37) without need for clinician scoring. The briefer ET4 performed as well as the full ET7.ConclusionET are quick, sensitive and useful screening tools for depression in this MS population, to be complemented by further questioning or more detailed psychiatric assessment where indicated. Given that ET4 and ET7 perform equally well, we recommend the use of ET4 as it is briefer. It has the potential to be widely implemented across busy neurology clinics to assist in depression screening in this under diagnosed group.

Functional non-epileptic attacks (FNEA) are seizure-like events occurring in the absence of epilepsy. Having had many different names over the years including dissociative convulsions and pseudo-seizures, they now fall in the borderland between neurology and psychiatry, often not accepted by either specialty. However, there is evidence that there is a high rate of psychiatric comorbidity in these patients and therefore it is likely that psychiatrists will come across patients with FNEA and they should know the broad principles of assessment and management.We have provided a clinically based overview of the evidence regarding epidemiology, risk factors, clinical features, differentiation from epilepsy, prognosis, assessment and treatment.By the end of this article, readers should be able to understand the difference between epileptic seizures and FNEA, know how to manage acute FNEA, and understand the principles of neuropsychiatric assessment and management of these patients, based on knowledge of the evidence base.Consent statementInformed consent was obtained from the patient for publication of Box 1.Declaration of interestNone.

Background: Capgras’ delusion has captured psychiatrists’ imaginations, but the clinical features of the delusion have rarely been studied and presented systematically. Aims: The present study systematically reviews all case reports on Capgras’ delusion in the English language in order to better understand differences between organic and functional aetiologies. Methods: All medical and psychiatric databases were searched, as were the bibliographies of published case reports, narrative reviews, and book chapters. Results: A total of 258 cases were identified from 175 papers. Functional Capgras’ delusion was more associated with a wider variety of imposters; multiple imposters; other misidentification syndromes; auditory hallucinations; other delusions; and formal thought disorder. Organic cases were associated with age; inanimate objects; memory and visual-spatial impairments; right hemispheric dysfunction; and visual hallucinations. Executive dysfunction and aggression were associated with both types. Conclusions: Specific features of the ­Capgras’ delusional content and associated signs point to either organic or functional aetiology. The delusion is more amorphous than many theorists have supposed, which challenges their explanatory models.

Referred to by the ancient Greeks as ‘Hysteria’, functional neurological disorders (FNDs) are one of the most prevalent diagnoses made in neurology clinics. Nonetheless, in part, due to the uncertainty regarding the potential voluntariness of such conditions, diagnostic and treatment services for FNDs are underdeveloped by comparison to those for other causes of neurological symptoms. This chapter discusses historical approaches to the classification and approach to FNDs, before moving on to contemporary treatments for it. Various treatments are then described with regard to certain forms of FNDs, such as the effects of cognitive behavioural therapy (CBT) and psychodynamic interpersonal therapy on functional non-epileptic attacks and multidisciplinary inpatient treatment, physiotherapy, and hypnosis on functional motor disorder. Finally, the relative lack of treatment options for functional cognitive disorder (FCD) is discussed, along with the initial findings of a pilot randomized controlled trial for it.

Acquired brain injuries (ABIs) can be categorized as traumatic or non-traumatic brain injuries. Traumatic brain injuries (TBIs), sub-classified as either open or closed TBIs, depending on whether there is a fracture of the skull or a breach of the dura mater, are typically caused by a physical impact such as blunt trauma or a fall. Non-TBIs can be caused by cerebrovascular events, infections, or chemical factors. This chapter predominantly focuses on TBIs, exploring techniques to measure their extent, such as the Glasgow Coma Scale (GCS), and the aetiology of TBIs. Moreover, the long-term effects of TBIs are explored, such as anxiety disorders which often present themselves in their aftermath and the likelihood for TBI-induced personality change. The associated effects of non-TBIs are then examined, specifically with reference to anoxic brain injuries and those induced by drugs or alcohol.

OBJECTIVES: Mild traumatic brain injury (mTBI) is a controversial and under-researched area, despite most traumatic brain injuries being classed as mild. Our objective was to review the evidence underpinning these approaches to treat mTBI including educational, psychological, rehabilitative and pharmacological approaches and discuss their efficacy. METHODS: A systematic review of literature was carried out using Web of science, Scopus, Medline, Pubmed, Cinahl, and PsychInfo databases. Randomized Controlled Trials (RCTs) looking at treatment outcome in mTBI for adults were included, published between 1980 and 2019. Methodological quality of the studies was reviewed using the Scottish Intercollegiate Guideline Network (SIGN) checklist for RCTs. RESULTS: Searches identified 3993 studies, of which 25 met inclusion criteria, and a total number of participants of 3213. Mean age was 35, and 59% male. Ten studies had

There is considerable debate in the literature regarding what to call functional seizures, with terms such as pseudoseizures, nonepileptic attack disorder (NEAD), and dissociative seizures being used. Provision of an accurate diagnosis and coherent explanation is a vital first step in the management of functional seizures and can result in cessation or reduced frequency for some individuals. This study investigated preferences for and offensiveness of terms used to describe functional seizures, and expectations for recovery with psychological treatment. A sample of 87 healthy adults completed an online survey, in which eight different diagnostic terms were ranked in order of preference (1 — most preferred, 8 — least preferred): functional nonepileptic attacks (FNEA), dissociative seizures, functional seizures, psychogenic seizures, NEAD, pseudoseizures, conversion disorder, and hysteria. Replicating Stone and colleagues protocol, each term was investigated for five connotations. Offense scores were calculated from the number of participants who selected ‘yes’ to at least one of the negative connotations (‘Putting it on’, ‘Mad’, and ‘Imagining Symptoms’). Expectations about the possibility of recovering through medical or psychological treatment were also recorded. Functional nonepileptic attack was ranked the highest preferred term with dissociative seizures and functional seizures closely following. Nonepileptic attack disorder was the least offensive term, with FNEA and functional seizures joint second. Unsurprisingly, the three least preferred terms were also the most offensive: pseudoseizures, conversion disorder, and hysteria. Expectations of nonrecovery from psychological treatment were lowest for terms implicating a psychological cause: pseudoseizures, dissociative seizures, psychogenic seizures, and hysteria. The results suggest that either the terms FNEA or functional seizures should be adopted by healthcare professionals and patients, as they are the most preferred, least offensive, and expectations for nonrecovery with psychological treatment were moderate compared with the other terms. Limitations and areas for future research are discussed.

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

Aims and methodPsychiatric disorders are common in neurological in-patients, but they are under-recognised and undertreated. We investigated the frequency of detection of mental disorder and referral to psychiatric services in a regional neuroscience centre. The results were compared with the expected prevalence. All in-patient referrals received in 2014 from the in-patient wards of the regional neuroscience centre and acute neurological unit were reviewed.ResultsA total of 129 ward referrals were identified; of these, 78 were from the regional in-patient neurological unit, which comprised 11.4% of the total of 679 admissions to that unit.Clinical implicationsA spectrum of neuropsychiatric conditions were recognised by neurologists, but overall rates of recognition were low. To address the problem of under-recognition, routine screening with validated assessment tools can represent a cost-effective and acceptable method to detect psychiatric disorders in an in-patient neurological setting.Declaration of InterestNone.

Patients who experience functional non-epileptic attacks (FNEA) are frequently seen in Neurology clinics. Diagnosis alone can result in cessation of attacks for some patients, but many patients require further treatment. There is evidence that certain psychological therapies, like cognitive-behavioral therapy (CBT) and psychodynamic interpersonal therapy (PIT) can be beneficial. Acceptance and commitment therapy (ACT) is a type of CBT that has been found to be effective at treating other somatic disorders, like epilepsy and chronic pain. In this paper, we explain what ACT is, the current evidence-base for its use, and the rationale for why it may be a beneficial treatment for patients who experience FNEA. We conclude that ACT is a potential treatment option for FNEA, and further research is required.

Behavioural changes associated with epilepsy can be challenging for patients and clinicians. Evidence suggests an association between aggression and epilepsy that involves various neurophysiological and neurochemical disturbances. Anti-epileptics have variable effects on behaviour and cognition that need consideration. Early detection and careful consideration of history, symptomatology and possible common comorbid psychiatric disorders is essential. Appropriate investigations should be considered to aid diagnosis, including electroencephalogram (EEG), video EEG telemetry and brain imaging. Optimising treatment of epilepsy, treatment of psychiatric comorbidities and behavioural management can have a major positive effect on patients' recovery and well-being.Learning Objectives• Understand the epidemiology of aggression in epilepsy• Comprehend the link between anti-epileptics and aggression, including the important role of pharmacodynamics• Be aware of the pharmacological treatments available for managing aggressive behaviour in epilepsy

A high proportion of patients presenting at epilepsy clinics experience functional non-epileptic attacks (FNEA), and while psychological treatment is generally thought to be the required intervention, evidence regarding psychological treatment of FNEA is limited. A small number of psychoeducation treatments have been evaluated, with promising results. As part of routine care within a neuropsychiatry service, a 3-session cognitive-behavior therapy- (CBT-) informed psychoeducation group was developed. Patients with comorbid epilepsy were included. The group's effectiveness was evaluated in terms of attack frequency, mood, illness perception, dissociative experiences, and patient feedback. Pre- and post-treatment data were obtained for 19 patients. The proportion of patients experiencing attacks significantly decreased, with almost 40% of treatment completers reporting being attack-free at the end of treatment. Significant improvements were also found on level of psychological distress, illness beliefs, and understanding of the condition. No significant changes in mood or general functioning were observed. High satisfaction was reported by almost all patients. Treatment outcome was not significantly affected by the level of dissociative experiences. The results suggest that CBT-based psychoeducation group treatment can be a beneficial part of treatment for those with FNEA, even for those experiencing high levels of dissociation. Further controlled studies with larger sample sizes are required.

Objectives The continuity and integrity of a conscious sense of self, is proposed to be dependent upon the control of internal physiological state and its predictive representation through interoception, that is, the sensing of internal bodily changes. We investigated dissociation, interoception and their relationship, in patients with functional seizures (FS), before and after a stressor intervention. Methods 41 participants with functional seizures (FS) and 30 age/gender matched healthy controls (HC) were assessed with the somatoform dissociation questionnaire (SDQ20), multi-scale dissociation inventory (MDI), and the state and trait anxiety inventory (STAI). Standardized measures of interoceptive sensibility, accuracy, and awareness were acquired with the Porges Body Perception Questionnaire (PBPQ), and heartbeat discrimination (HDT), tracking (HTT) and time-tracking tasks (TTT), before and after a cold pressor test. Continuous non-invasive blood pressure monitoring was carried out before, during and after the cold pressor test. Interoceptive trait (ITPE) and state (ISPE) prediction errors, that is, the discrepancy between interoceptive accuracy and the PBPQ (trait), and trial-by-trial confidence estimates (state), were calculated before and after the cold pressor test respectively, for HTT and HDT. An autonomic prediction error (APE), or the discrepancy between the reported increase in pain and the change in blood pressure after the cold pressor, was also calculated. Results Patients with FS differ significantly from HC for HTT, ITPE and ISPE suggesting that they are overall less interoceptively accurate and aware than HC. This is confirmed by a correlation between APE and the ISPE derived from the HDT task (r=0.359, p=0.033) in FS subjects only, after correcting for state anxiety and duration of cold pressor. Furthermore, in FS patients only, ITPE scores, adjusted for trait anxiety, correlated with SDQ-20 and MDI-depersonalization scores for both HTT (r=0.378, p=0.008; r=0.408, p=0.005) and HDT (r=0.364, p=0.011; r=0.281, p=0.044). All results survived FDR correction at a 0.05 threshold. Conclusions These findings demonstrate that state and trait interoception are disrupted in patients with FS. The severity of the disruption in trait interoception correlates with measures of dissociation, such that the bigger the ITPE, the more severe are the dissociative traits. Similarly, the greater the ISPE, the larger the discrepancy between subjective symptoms and objective physiological changes, after a stressor intervention. Our findings suggest that the selective disruption of interoceptive processing is both a potential predisposing and precipitating factor in FS.

Summary Objective Functional seizures are a common functional neurologic disorder. Given their chronic nature, and the biopsychosocial factors involved in their etiology, general practitioners (GPs) play a crucial role in the care of these patients. However, little is known about the attitudes of GPs toward, and knowledge of, functional seizures. Methods The Atkinson Morley Regional Neuroscience Centre in London provides a comprehensive service to patients with functional seizures. As part of a service evaluation we conducted an online survey among local GPs over a 1‐month period assessing their attitudes toward, and knowledge of, functional seizures. Results One hundred twenty of 974 surveyed GPs replied to the survey (12.3%). Approximately 75% of GPs readily use the term “pseudoseizures,” and over 50% were not sure or did not think that functional seizures were involuntary. Nearly 30% believed, or were unsure as to whether, functional seizures occur only when patients are stressed. Despite approximately 50% of GPs expressing interest in getting involved in the management of these patients, a similar proportion do not feel confident in dealing with queries from patients with functional seizures. Although most GPs felt that neurology and psychiatry should be the primary caregivers in the diagnosis and management, respectively, of functional seizures, 50% were also of the opinion that neurology should be involved in the management of these patients. Significance This survey highlights the attitudes of, and descriptive terms used by, GPs toward patients with functional seizures. Our findings suggest a need for better and clearer provision of information to GPs about this condition.

Psychosis is a severe psychiatric condition with frightening experiences and is five times more common in people with epilepsy. Since the 4th century BCE, epilepsy and psychosis were both thought of as behavioral or mental illness and managed in a similar way; only in the 19th century was epilepsy properly understood initially by Jackson. In 1950 Landolt coined the term “forced normalization” highlighting the complex relationship epilepsy and psychosis have, highlighting the antagonistic properties that seizures and psychosis have, and explaining why treatment for epilepsy can trigger psychosis. Psychosis in epilepsy is more frequently seen in temporal lobe epilepsy, hippocampal sclerosis and lesions in frontal areas, abnormalities likely to involve the limbic structures. Lesions that make epileptic patients more vulnerable to psychosis could be neurodevelopmental, leading to cortical dysgenesis, or acquired. This could trigger kindling mechanisms or regenerative changes (axonal sprouting and synaptic reorganization), causing modulation of catecholamine, glutamate, and gamma-Aminobutyric acid pathways. Case studies have illustrated that antipsychotic drugs can be used to control psychosis of epilepsy, without worsening seizures. There can also be a therapeutic role of electroconvulsive therapy in some refractory cases.

This study explored the preferred terms for functional seizures, and the experience of being diagnosed, from the patient’s perspective. 39 patients in a neuropsychiatry service diagnosed with functional seizures completed an online survey to investigate preferences for, and offensiveness of, 11 common diagnostic terms used to describe functional seizures. Of these 39 patients, 13 consented to take part in a semistructured interview exploring the experience of receiving a diagnosis. Nonepileptic attack disorder (NEAD), functional seizures, functional nonepileptic attacks (FNEA), and dissociative seizures were ranked the highest preferred terms and did not significantly differ from one another. NEAD was the least offensive term, with functional seizures and FNEA following closely. Significant overlap in confidence intervals was found between the offensiveness of all terms. Terms that indicated a psychological origin were the least preferred and viewed as most offensive. Thematic analysis identified three main themes on the experience of being diagnosed: ‘being heard and having a shared understanding’, ‘feeling alone’, and ‘sense of hope’. Patients favored diagnostic terms that facilitated and alleviated these themes on a personal basis; however, preferences differed across individuals. Our findings suggest that a range of terms have a similar level of preference and offense rating, with NEAD, functional seizures, and FNEA being the most favorable. Qualitative analysis indicates that a term and its accompanying explanation should facilitate shared acceptance and understanding, and several terms provide this. In combination with our previous study on healthy participants, we propose that one of the two terms researched are adopted by patients, health professionals, and the public: Functional nonepileptic attacks or Functional seizures.

Purpose A number of studies have suggested that depressed mood is one of the most important predictors of quality of life (QoL) in patients with epilepsy. However, the QoL measure used in previous studies was limited to the Quality of Life in Epilepsy (QOLIE) scales. It could be questioned whether correlation of QOLIE with measures of depression is influenced by the properties of the instruments used rather than being a valid effect. By using visual analogue scales, the current study aimed to clarify whether depression and QoL are truly correlated in patients with epilepsy. Methods Data from a sample of 261 outpatients with epilepsy attending the Epilepsy Clinics of the Atkinson Morley Outpatient Department, St George's Hospital in London, were analyzed. Patients were screened using the European Quality-of-Life scale (EQ-5D-3L) which includes an overall visual analogue score (EQ-VAS), the Emotional Thermometer (ET7), the Beck Depression inventory—II (BDI-II), the Hospital Anxiety and Depression scale (HADS), and the Major Depression inventory (MDI). Results Depression was found to significantly correlate with EQ-VAS score with r coefficient ranging from 0.42 to 0.51 and r 2 coefficients ranging between 0.18 and 0.26. In addition, we identified patients who were depressed according to DSM-IV criteria (MD) and those with atypical forms of depression (AD). The EQ-5D-3L scores in these subjects compared with those without depression (ND) showed a different impact of AD and MD on QoL. Conclusions The relationship between depression and QoL in people with epilepsy has been demonstrated to be a robust and valid effect, not a result of potential bias of the specific measures used. However, the strength of the association is influenced by the individual instrument. Atypical or subsyndromic forms of depression are as relevant as DSM-based depression in terms of impact on QoL.

In March 2014, a UK Supreme Court case, known as Cheshire West, reached a judgement that greatly expanded the group of people in England and Wales who could be considered deprived of their liberty when under the care of the state. This now includes anyone meeting what is known as the 'acid test': whether the person is under 'continuous supervision and control' and 'not free to leave'. The case concerned three people with learning disability, living in community residential placements; all were judged to have been deprived of their liberty, despite being apparently content, and having 'relative normality' for people in their situation. Many people consider the case to apply to hospital settings. Clearly, many neurosciences inpatients are under 'continuous supervision and control'. This might include being told when to eat or sleep, what medication to take or being under close nursing observation. Many also are not free to leave because of safety concerns. Inpatients may also be eligible for detention under Mental Health Act--if they have a mental disorder sufficient to warrant this--such as a risk to that person's health or safety, or the safety of others. Thus, we have a confusing combination of two laws that might apply. This article aims to demystify the legal background and apply it to clinical practice in England and Wales and elsewhere.

The purpose of this study was to identify clinical correlates of self-reported aggressiveness (SRA) in patients with epilepsy treated with levetiracetam (LEV) with special reference to the role of depression.A consecutive sample of adult outpatients with epilepsy was assessed with the Neurological Disorder Depression Inventory for Epilepsy, the Adverse Event Profile (AEP), and the Emotional Thermometer.From a total sample of 163 consecutive patients treated with LEV, SRA at any level (from rarely a problem to always) was associated with a 7-fold increased risk of being depressed (95% CI: 3.0-17.5; p0.001). Self-reported aggressiveness was reported as "always" a problem by 9.8% of the patients. In these patients, apart from depression, SRA was associated with high AEP total scores (55.1 vs. 39.3; p0.001) and polytherapy (43.8% vs. 19.8%; p=0.034). Anxiety scores were not elevated (4.9 vs. 3.6; p=0.183).Self-reported aggressiveness during treatment with LEV is not an isolated symptom but is associated with depressed mood. Anxiety-mediated mechanisms do not seem to be involved.

Objective Depression is common but frequently underdiagnosed in people with epilepsy. Screening tools help to identify depression in an outpatient setting. We have published validation of the NDDI-E and Emotional Thermometers (ET) as screening tools for depression (Rampling et al., 2012). In the current study, we describe a model of an optimized screening tool with higher accuracy. Methods Data from 250 consecutive patients in a busy UK outpatient epilepsy clinic were prospectively collected. Logistic regression models and recursive partitioning techniques (classification trees, random forests) were applied to identify an optimal subset from 13 items (NDDI-E and ET) and provide a framework for the prediction of class membership probabilities for the DSM-IV-based depression classification. Results Both logistic regression models and classification trees (random forests) suggested the same choice of items for classification (NDDI-E item 4, NDDI-E item 5, ET-Distress, ET-Anxiety, ET-Depression). The most useful regression model includes all 5 mentioned variables and outperforms the NDDI-E as well as the ET with respect to AUC (NDDI-E: 0.903; ET7: 0.889; logistic regression: 0.943). A model developed using random forests, grown by restricting the possible splitting of variables to these 5 items using only subsets of the original data for single classification, performed similarly (AUC: 0.949). Conclusions For the first time, we have created a model of a screening tool for depression containing both verbal and visual analog scales, with characteristics supporting that this will be more precise than previous tools. Collection of a new data sample to assess out-of-sample performance is necessary for confirmation of the predictive performance.

Aims and methodPrevious studies have shown variations in commissioning of neuropsychiatry services and this makes access to neuropsychiatric services a postcode lottery. In this survey, we approached all mental health and neuropsychiatric service commissioners within London to map current funding and commissioning arrangements, and explored perceived barriers to neuropsychiatric service commissioning.Results 83% of commissioners within London responded. There was significant variability between neuropsychiatric services commissioned through the mental health stream. Contracting arrangements were variable. Lack of earmarked fund for neuropsychiatry and disjointed funding stream for such services were identified by commissioners as a barrier, as was the critical mass of neuropsychiatric cases.Clinical implicationsNeuropsychiatric service development continues to be hindered by lack of clear commissioning process. Strategic drive is needed to promote more equitable neuropsychiatric services. National or regional commissioning covering a large population will provide a better model for neuropsychiatric services to be commissioned.

Purpose To examine the prevalence and clinical correlates of fatigue as an adverse event (AE) of antiepileptic drug (AED) treatment in patients with epilepsy. Methods Data from 443 adult outpatients with epilepsy assessed with the Adverse Event Profile (AEP) and the Neurological Disorder Depression Inventory for Epilepsy (NDDIE) were analysed. Results Fatigue is reported by 36.6% of patients as always a problem during AED treatment. Fatigue is more likely to be reported by females (64.8% vs. 35.2%; Chi-Square = 16.762; df = 3; p = 0.001) and during treatment with levetiracetam (42.3% vs. 33.2%; Chi-Square = 11.462; df = 3; p = 0.009). The associations with the female gender and levetiracetam treatment were not mediated by depression, as identified with the NDDIE, and could not be simply explained by the large number of subjects on levetiracetam treatment, as analogous figures resulted from the analysis of a monotherapy subsample (41.7% vs. 30.3%; Chi-Square = 11.547; df = 3; p = 0.009). Conclusions One third of patients with epilepsy reports fatigue as a significant problem during AED treatment. Fatigue is more likely to be reported by females and seems to be specifically associated with LEV treatment. However, fatigue is not mediated by a negative effect of LEV on mood.

Background and purpose People with epilepsy are at increased risk of accidents and injuries but, despite several studies on this subject, data regarding preventable causes are still contradictory. The aim of this study was to investigate the relationship between injuries, side effects of antiepileptic drugs (AEDs) and depression. Methods Data from a consecutive sample of adult patients with epilepsy attending the outpatient clinics at St George's University Hospital in London were included. All patients were asked if they had had any injury since the last clinic appointment and completed the Liverpool Adverse Event Profile (LAEP) and Neurological Disorders Depression Inventory for Epilepsy. Results Among 407 patients (243 females, mean age 43.1 years), 71 (17.4%) reported injuries since the last appointment. A two-step cluster analysis revealed two clusters with the major cluster (53.5% of the injured group) showing a total score for LAEP ≥45, a positive Neurological Disorders Depression Inventory for Epilepsy screening and presence of AED polytherapy. A total score for LAEP ≥45 was the most important predictor. Conclusions Antiepileptic drug treatment should be reviewed in patients reporting injuries in order to evaluate the potential contribution and burden of AED side effects.

Background Despite the long history of psychogenic nonepileptic seizures (PNES), relatively little is known about the mechanisms that cause and maintain this condition. Emerging research evidence suggests that patients with PNES might have difficulties in regulating their emotions. However, much remains to be learned about the nature of these difficulties and the emotional responses of individuals with PNES. This study aimed to gain a detailed understanding of emotion regulation processes in patients with PNES by examining differences between patients with PNES and a healthy control group with regard to intensity of emotional reactions, understanding of one's emotional experience, beliefs about emotions, and managing emotions by controlling emotional expression. Method A cross-sectional design was used to compare the group with PNES (n = 56) and the healthy control group (n = 88) on a range of self-report measures. Results Participants with a diagnosis of PNES reported significantly poorer understanding of their emotions, more negative beliefs about emotions, and a greater tendency to control emotional expression compared to the control group. While intensity of emotions did not discriminate between the groups, poor understanding and negative beliefs about emotions were found to be significant predictors of PNES, even after controlling for age, education level, and emotional distress. Furthermore, the presence of some emotion regulation difficulties was associated with self-reported seizure severity. Conclusions The results of this study are largely consistent with previous literature and provide evidence for difficulties in emotion regulation in patients with PNES. However, this research goes further in bringing together different aspects of emotion regulation, including beliefs about emotions, which have not been examined before. As far as it is known, this is the first study to suggest that levels of alexithymia in a population with PNES are positively associated with self-reported seizure severity. The findings suggest a need for tailored psychological therapies addressing specific emotion regulation difficulties in individuals with PNES.

Purpose Up to 60% of people with epilepsy (PwE) have psychiatric comorbidity including anxiety. Anxiety remains under recognized in PwE. This study investigates if screening tools validated for depression could be used to detect anxiety disorders in PWE. Additionally it analyses the effect of anxiety on QoL. Method 261 participants with a confirmed diagnosis of epilepsy were included. Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and Emotional Thermometers (ET), both validated to screen for depression were used. Hospital Anxiety and Depression Scale-Anxiety (HADS-A) with a cut off for moderate and severe anxiety was used as the reference standard. QoL was measured with EQ5-D. Sensitivity, specificity, positive and negative predictive value and ROC analysis as well as multivariate regression analysis were performed. Results Patients with depression (n=46) were excluded as multivariate regression analysis showed that depression was the only significant determinant of having anxiety in the group. Against HADS-A, NDDI-E and ET-7 showed highest level of accuracy in recognizing anxiety with ET7 being the most effective tool. QoL was significantly reduced in PwE and anxiety. Conclusion Our study showed that reliable screening for moderate to severe anxiety in PwE without co-morbid depression is feasible with screening tools for depression. The cut off values for anxiety are different from those for depression in ET7 but very similar in NDDI-E. ET7 can be applied to screen simultaneously for depression and "pure" anxiety. Anxiety reduces significantly QoL. We recommend screening as an initial first step to rule out patients who are unlikely to have anxiety.

Aims and methodNeuropsychiatry services remain underdeveloped and underprovided. Previous studies have shown variability in service provision in the UK. In this survey we approached all mental health and neuropsychiatric service providers within London to map current neuropsychiatric service provision and explore perceived barriers.ResultsAll the specialist mental health service providers responded. There was huge variability in neuropsychiatric service provision within different parts of London. There was evidence of significant unmet need and variability in service pathways. Lack of earmarked funds for neuropsychiatry and disjointed funding stream for such services were identified by providers as a barrier.Clinical implicationsThis study provides further evidence of an ongoing lack of adequate neuropsychiatric service provision. Reasons for variability and unmet need are discussed. Adoption of a previously proposed hub-and-spoke model of service provision and the removal of commissioning barriers through uniform national commissioning may help deal with this problem.

Summary Purpose: Depression is an important but underdiagnosed complication of epilepsy. This study compares potentially suitable screening tools head-to-head. Methods: We enrolled 266 attendees with a confirmed diagnosis of epilepsy at a specialized neurologic epilepsy service in London and compared verbal self-report and visual analog (VAS) screening methods for depression. These included two generic depression scales (Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory II [BDI-II]), one epilepsy specific scale (Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]) and one new visual-analog scale (Emotional Thermometers [ET]). We used Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major depression and International Classification of Diseases, Tenth Revision (ICD-10) criteria for depressive episode as the reference standard. Key Findings: Against ICD-10–defined depression the most accurate scales by receiver operating characteristic (ROC) curve area were HADS Total (HADS-T, 0.924), BDI-II (0.898) and NDDI-E (0.897). New visual-analog methods had similar accuracy measured either in combination or individually. Although no test performed well in a case-finding role, several performed well as a rule-out initial step, owing to high negative predictive value and specificity. In this role, the optimal performing conventional tools were the HADS depression subsscale (HADS-D) and the NDDI-E and the optimal single VAS were the depression thermometer (DepT) and the distress thermometer (DT). Against DSM-IV– defined major depression, results were similar with optimal performance by the HADS-T, BDI-II, and NDDI-E, but here the anxiety thermometer (AnxT) as well as DepT and DT also offered good performance. Given that no test performed well in a case-finding role, we suggest that these tests are used as an initial first step to rule out patients who are unlikely to have depression. Significance: We suggest that the six-item NDDI-E or seven-item HADS-D should be considered if a conventional scale is preferred and that the revised ET4 be considered if a visual-analog method is required. Follow-up examination and intervention, where indicated, are necessary in all those who screen positive on any measure as these are not intended as diagnostic tools.

SummaryCognitive dysfunction is one of the major contributors to the burden of epilepsy. It can significantly disrupt intellectual development in children and functional status and quality of life in adults. Epilepsy affects cognition through a number of mechanisms in complex interrelationship. Cognitive deficits in epilepsy may be treated indirectly through aggressive seizure control using anti-epileptic drugs or surgery, and by treating comorbid conditions such as depression. The beneficial effects of reducing seizures may offset the adverse cognitive side-effects of these therapies. Direct treatment of cognitive impairment in epilepsy mainly involves memory rehabilitation. Other direct treatments are mostly experimental and their evidence base is currently poor.

Objectives To investigate clinical correlates of memory complaints (MC) during anti-epileptic drug (AEDs) treatment in adults with epilepsy with special attention to the role of depression, using user-friendly standardized clinical instruments which can be adopted in any outpatient setting. Materials & methods Data from a consecutive sample of adult outpatients with epilepsy assessed with the Neurological Disorder Depression Inventory for Epilepsy (NDDIE), the Adverse Event Profile (AEP) and the Emotional Thermometer (ET) were analysed. Results From a total sample of 443 patients, 28.4% reported MC as ‘always’ a problem. These patients were less likely to be seizure free (18.3% vs 34.3%; P < 0.001), had a high number of previous AED trials (4 vs 3; P < 0.001) and high AEP total scores (49 vs 34.2; P < 0.001). There was no correlation with specific AED type or combination. Depression was the major determinant with a 2-fold increased risk (95%CI 1.15–3.86; P = 0.016). When depression was already known and under treatment, patients with MC were less likely to be in remission from depression despite antidepressant treatment (11.9% vs 1.6% P < 0.001). Among patients without depression, those reporting MC presented with significantly high scores for depression (3.3 vs 2; t = 3.07; P = 0.003), anxiety (4.5 vs 2.7; t = 4.43; P < 0.001), anger (3 vs 2; t = 2.623; P = 0.009) and distress (3.8 vs 2.2; t = 4.027; P < 0.001) than those without MC. Conclusions Depression has to be appropriately treated and full remission from depression should represent the ultimate goal as subthreshold or residual mood and anxiety symptoms can contribute to MC.

Background Traumatic brain injury (TBI) is a major cause of chronic disability. Worldwide, it is the leading cause of disability in the under 40s, resulting in severe disability in some 150 to 200 million people per annum. In addition to mood and behavioural problems, cognition—particularly memory, attention and executive function—are commonly impaired by TBI. Cognitive problems following TBI are one of the most important factors in determining people's subjective well-being and their quality of life. Drugs are widely used in an attempt to improve cognitive functions. Whilst cholinergic agents in TBI have been reviewed, there has not yet been a systematic review or meta-analysis of the effect on chronic cognitive problems of all centrally acting pharmacological agents. Objectives To assess the effects of centrally acting pharmacological agents for treatment of chronic cognitive impairment subsequent to traumatic brain injury in adults. Search methods We searched ALOIS—the Cochrane Dementia and Cognitive Improvement Group’s Specialised Register—on 16 November 2013, 23 February 2013, 20 January 2014, and 30 December 2014 using the terms: traumatic OR TBI OR "brain injury" OR "brain injuries" OR TBIs OR "axonal injury" OR "axonal injuries". ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases, numerous trial registries and grey literature sources. Supplementary searches were also performed in MEDLINE, EMBASE, PsycINFO, The Cochrane Library, CINAHL, LILACs, ClinicalTrials.gov, the World Health Organization (WHO) Portal (ICTRP) and Web of Science with conference proceedings. Selection criteria We included randomised controlled trials (RCTs) assessing the effectiveness of any one centrally acting pharmacological agent that affects one or more of the main neurotransmitter systems in people with chronic traumatic brain injury; and there had to be a minimum of 12 months between the injury and entry into the trial. Data collection and analysis Two review authors examined titles and abstracts of citations obtained from the search. Relevant articles were retrieved for further assessment. A bibliographic search of relevant papers was conducted. We extracted data using a standardised tool, which included data on the incidence of adverse effects. Where necessary we requested additional unpublished data from study authors. Risk of bias was assessed by a single author. Main results Only four studies met the criteria for inclusion, with a total of 274 participants. Four pharmacological agents were investigated: modafinil (51 participants); (−)-OSU6162, a monoamine stabiliser (12 participants of which six had a TBI); atomoxetine (60 participants); and rivastigmine (157 participants). A meta-analysis could not be performed due to the small number and heterogeneity of the studies. All studies examined cognitive performance, with the majority of the psychometric sub-tests showing no difference between treatment and placebo (n = 274, very low quality evidence). For (−)-OSU6162 modest superiority over placebo was demonstrated on three measures, but markedly inferior performance on another. Rivastigmine was better than placebo on one primary measure, and a single cognitive outcome in a secondary analysis of a subgroup with more severe memory impairment at baseline. The study of modafinil assessed clinical global improvement (n = 51, low quality evidence), and did not find any difference between treatment and placebo. Safety, as measured by adverse events, was reported by all studies (n = 274, very low quality evidence), with significantly more nausea reported by participants who received rivastigmine compared to placebo. There were no other differences in safety between treatment and placebo. No studies reported any deaths. Authors' conclusions There is insufficient evidence to determine whether pharmacological treatment is effective in chronic cognitive impairment in TBI. Whilst there is a positive finding for rivastigmine on one primary measure, all other primary measures were not better than placebo. The positive findings for (−)-OSU6162 are interpreted cautiously as the study was small (n = 6). For modafinil and atomoxetine no positive effects were found. All four drugs appear to be relatively well tolerated, although evidence is sparse.

Nimmagadda SR, Agrawal N, Worrall-Davies A, Markova I, Rickards H. Determinants of irritability in Huntington's disease.Objectives: Irritability is a common and disabling problem associated with Huntington's disease (HD). However, the underlying causes of such irritability remain unclear. This study investigates the association of irritability in HD with possible aetiological factors including dysexecutive syndrome, depression, anxiety (state and trait) and movement disorder.Methods: Thirty patients with genetically confirmed HD and their carers were recruited from a regional HD neuropsychiatry service. Patients completed two self-reported questionnaires (Irritability, Anxiety and Depression Scale and State Trait Anxiety Inventory). Their carers filled in the Burns Irritability Scale. Patients were also administered the Behavioural Assessment of Dysexecutive Syndrome (BADS), Montgomery and Asberg Depression Rating Scale (MADRS) and the Motor component of the Unified Huntington's Disease Rating Scale (UHDRS).Results: Both self-rated and carer-rated irritability scales showed significant positive correlation with trait anxiety. The self-rated irritability scales also showed significant positive correlation with state anxiety and depression. No association was observed between irritability and dysexecutive syndrome or motor impairment.Conclusions: Trait anxiety might serve as a predictor for irritability in HD. Irritability is unrelated to motor or cognitive features of HD indicating that it is an independent neuropsychiatric manifestation of HD.

SummaryEpilepsy is a common neurological condition with wide-ranging neuropsychiatric manifestations. The relationship between epilepsy and psychiatry has been recognised for centuries. However, the wide range of neuropsychiatric comorbidities and their extent is only now beginning to be appreciated. The impact of these comorbidities on patients' help-seeking behaviour, seizure control and quality of life suggests that early detection and treatment are of paramount importance. Clinical issues in relation to accurate recognition and appropriate management of neuropsychiatric conditions in epilepsy are discussed.

SummaryDementia is is stereotypically associated with older people. However, in a significant minority it can affect people in their 40s and 50s, or even younger. Currently there is a lack of awareness, even among healthcare professionals, and there is a dearth of appropriate services for such patients. Despite the attention given to this condition by National Institute for Health and Clinical Excellence guidelines, provision of specialist early-onset dementia services in the UK remains patchy. Carers and patients often find themselves being passed ‘from pillar to post’ between psychiatry and neurology, and also between adult, old age and liaison psychiatry. The responsibility for identifying available and appropriate help is often left with carers. This leads to unnecessary delays, causes undue distress to patients and places an added burden on carers.