Medication prescriptions in 322 motor functional neurological disorder patients in a large UK mental health service: A case control study

Efficacy of patient education and duloxetine, alone and in combination, for patients with multisystem functional somatic disorder: Study protocol for the EDULOX trial

BACKGROUND

Multisystem functional somatic disorder is characterized by specific patterns of persistent physical symptoms with a complex biopsychosocial etiology. The disorder can lead to disability and personal suffering. Current treatment options require specialized settings, therefore patients often wait a long time to receive specific treatment. Patient education is considered important in most treatment programs, but has only been investigated sparsely as a stand-alone treatment. Pharmacological treatment is limited to tricyclic antidepressants in low doses with no antidepressant properties. Duloxetine has been found effective in single organ functional disorders. As a treatment for multisystem functional somatic disorder, duloxetine could reduce symptoms and treat comorbid anxiety and depression. It may furthermore enhance the effect of patient education through a hypothesized effect on cognitive functioning. The purpose of the EDULOX trial is to study psycho-EDUcation and duLOXetine alone and in combination.

METHODS

This is a nested study design. The parent trial "EDULOX1" (n = 424) will compare a patient education program with enhanced usual care in an open-labelled, randomized controlled trial. In addition to this, eligible participants will furthermore receive either duloxetine or active placebo in the nested, double-blinded, randomized controlled trial, "EDULOX2" (n = 212). Patient and clinician reported outcomes will be collected through questionnaires.

CONCLUSION

The EDULOX trial may establish evidence for treatments applicable for the majority of patients with multisystem functional somatic disorder. If effective, duloxetine would be a more tolerable pharmacological treatment option that can target comorbid depression and anxiety, and potentially boost the effect of patient education. Trial registration number The study is registered at www.

CLINICALTRIALS

gov (NCT06232473) and the internal list of research projects at the Region of Central Denmark (Case number 1-16-02-305-23). Approval from the Danish Medical Research Ethics Committees (Case number: 2212291) and the Danish Medicines Agency was obtained under EudraCT Number: 2022-002780-30 and Sponsor's Protocol Code Number: 9515.

Psychological interventions for treating functional motor symptoms: A systematic scoping review of the literature

Functional Movement Disorders (FMD) can be identified by limb weakness, gait disorders, or involuntary movements which are inconsistent with a neurological diagnosis. Despite the prevalence of such symptoms, there has been little consensus on models for treatment. This scoping review set out to identify the literature exploring the efficacy of psychological interventions for the treatment of FMD, either as a stand-alone intervention or as part of a multi-disciplinary team approach. Studies set in an adult inpatient and outpatient setting were considered for inclusion. The final review consisted of 33 papers; 13 reviewing psychological treatments only, and 20 reviewing multidisciplinary approaches that included a psychological intervention. This review of the literature reaffirms the inconsistency across treatment for FMD, although identifies a trend towards an MDT approach in recent years. The review also identifies areas where consistency in methodology may be beneficial in future research, in order to improve the validity of results for greater comparison of treatments. There are promising outcomes that support the continued investigation focused on an interdisciplinary, collaborative approach to care, for the reduction of symptoms.

International online survey of 1048 individuals with functional neurological disorder

BACKGROUND AND PURPOSE

Functional neurological disorder (FND) is common, and symptoms can be severe. There have been no international large-scale studies of patient experiences of FND.

METHODS

A patient questionnaire was created to assess FND patient characteristics, symptom comorbidities and illness perceptions. Respondents were recruited internationally through an open access questionnaire via social media and patient groups over a month-long period.

RESULTS

In total, 1048 respondents from 16 countries participated. Mean age was 42 years (86% female). Median FND symptom duration was 5 years, and median time from first symptom to diagnosis was 2 years. Mean number of current symptoms (core FND and associated) was 9.9. Many respondents had associated symptoms, for example fatigue (93%), memory difficulties (80%) and headache (70%). Self-reported psychiatric comorbidities were relatively common (depression, 43%; anxiety, 51%; panic, 20%; and post-traumatic stress disorder, 22%). Most respondents reported that FND had multiple causes, including physical and psychological.

CONCLUSIONS

This large survey adds further evidence that people with FND typically have high levels of multiple symptom comorbidity with resultant distress. It also supports the notion that associated physical symptoms are of particular clinical significance in FND patients. Dualistic ideas of FND were not supported by respondents, who generally preferred to conceptualize the disorder as one at the interface of mind and brain. The need for a broad approach to this poorly served patient group is highlighted. Potential selection and response biases due to distribution of the survey online, mostly via FND patient groups, are a key limitation.

Interoception and stress in patients with Functional Neurological Symptom Disorder

INTRODUCTION

Research suggests that patients with Functional Neurological Symptom Disorder (pwFND) struggle to identify their own emotions and associated physiological cues (interoceptive sensitivity, IS). However, it is not known how this deficit interacts with stress. This study aimed to assess IS in pwFND at baseline and following stress induction, and relate the findings to self-reported emotion processing difficulties.

METHODS

Twenty-six pwFND and 27 healthy controls performed the Heart Beat Detection Task pre- and post-stress induction with the Cold Pressor Test. Participants also completed questionnaires assessing anxiety (GAD-7) and depressive symptomology (PHQ-9), as well as emotion processing (EPS-25).

RESULTS

Patients reported deficits in emotion processing (p < . 001) and had lower IS (p = .032) than healthy controls. IS improved following stress induction across both groups (p = .003) but patients' IS was lower than that of healthy controls' pre-and post-stress induction. Exploratory analyses revealed that patients reporting sensory symptoms had lower IS at baseline than patients who did not.

CONCLUSION

Our findings suggest that pwFND are relatively impaired in the identification of their emotions at baseline and following stress induction. This may be related to the experience of functional sensory symptoms and has implications for the psychological treatment of emotion dysregulation in this population.

Functional pain disorders - more than nociplastic pain

BACKGROUND

Nociplastic pain has been recently introduced as a third mechanistic descriptor of pain arising primarily from alterations of neural processing, in contrast to pain due to tissue damage leading to nociceptor activation (nociceptive) or due to lesion or disease of the somatosensory nervous system (neuropathic). It is characterized by hyperalgesia and allodynia, inconsistency and reversibility, as well as dynamic cross-system interactions with biological and psychobehavioral factors. Along with this renewed understanding, functional pain disorders, also classified as chronic primary pain, are being reframed as biopsychosocial conditions that benefit from multimodal treatment.

OBJECTIVE

To summarize the current understanding of nociplastic pain and functional pain disorders, with a focus on conditions that are common in neurology practice.

METHODS

This was a narrative literature review.

RESULTS

Chronic back pain, fibromyalgia syndrome and complex regional pain syndrome are best understood within a biopsychosocial framework of pain perception that considers structural factors (predispositions and sequelae) and psychobehavioral mechanisms. Although pain is often the primary complaint, it should not be the only focus of treatment, as accompanying symptoms such as sleep or mood problems can significantly impact quality of life and offer useful leverage points for multimodal treatment. Analgesic pharmacotherapy is rarely helpful on its own, and should always be imbedded in a multidisciplinary setting.

The prevalence, trends and determinants of mental health disorders in older Australians living in permanent residential aged care: Implications for policy and quality of aged care services

OBJECTIVE

Mental health disorders are a major health concern in older people and are associated with a higher risk of disability, frailty and early mortality. This study aimed to conduct a contemporary population-based assessment of the prevalence, trends and factors associated with mental health disorders in individuals who are living in permanent residential aged care (PRAC) in Australia.

METHODS

A retrospective cross-sectional study was conducted using national data from the Registry of Senior Australians, a national cohort of older Australians who had aged care eligibility assessment and entered PRAC between 2008 and 2016. Stepwise multivariate logistic regression modeling was applied to identify factors associated with mental health disorders.

RESULTS

Of 430,862 individuals included in this study, 57.8% had at least one mental health disorder. The prevalence of depression, phobia/anxiety and psychosis were as follows: 46.2% (95% confidence interval = [46.0%, 46.3%]), 14.9% (95% confidence interval = [14.8%, 15.0%]) and 9.7% (95% confidence interval = [9.6%, 9.8%]), respectively. The likelihood of having a mental health disorder was higher for those who were (adjusted odds ratio [95% confidence interval]) relatively younger, specifically for every 10-year increment in age, the odds of having mental health disorders was 44.0% lower (0.56, [0.55, 0.56]); female (1.33 [1.32, 1.35]); having increasing numbers of physical health comorbidities, 6-10 (1.26 [1.24, 1.29]) or 11-15 (1.48 [1.45, 1.51]) or more than 15 (1.64 [1.58, 1.71]) compared to people having less than five comorbidities; having limitations related to health care tasks (1.05 [1.04, 1.07]), meals (1.04 [1.02, 1.05]) or social and community participation (1.10 [1.08, 1.12]).

CONCLUSION

The burden of mental health disorders in older Australians living in PRAC was high and individuals with these conditions tend to be younger, with several physical comorbidities and/or functional limitations. Understanding the profile of individuals with mental health disorders at entry into PRAC can be used as evidence for baseline resource allocation for this population and evaluation of future needs of mental health services.