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Chalder T, Landau S, Stone J, Carson A, Reuber M, Medford N, Robinson EJ, Goldstein LH. How does cognitive behavior therapy for dissociative seizures work? A mediation analysis of the CODES trial. Psychol Med 2024; 54:1725-1734. [PMID: 38197148 DOI: 10.1017/s0033291723003665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND We compared dissociative seizure specific cognitive behavior therapy (DS-CBT) plus standardized medical care (SMC) to SMC alone in a randomized controlled trial. DS-CBT resulted in better outcomes on several secondary trial outcome measures at the 12-month follow-up point. The purpose of this paper is to evaluate putative treatment mechanisms. METHODS We carried out a secondary mediation analysis of the CODES trial. 368 participants were recruited from the National Health Service in secondary / tertiary care in England, Scotland, and Wales. Sixteen mediation hypotheses corresponding to combinations of important trial outcomes and putative mediators were assessed. Twelve-month trial outcomes considered were final-month seizure frequency, Work and Social Adjustment Scale (WSAS), and the SF-12v2, a quality-of-life measure providing physical (PCS) and mental component summary (MCS) scores. Mediators chosen for analysis at six months (broadly corresponding to completion of DS-CBT) included: (a) beliefs about emotions, (b) a measure of avoidance behavior, (c) anxiety and (d) depression. RESULTS All putative mediator variables except beliefs about emotions were found to be improved by DS-CBT. We found evidence for DS-CBT effect mediation for the outcome variables dissociative seizures (DS), WSAS and SF-12v2 MCS scores by improvements in target variables avoidance behavior, anxiety, and depression. The only variable to mediate the DS-CBT effect on the SF-12v2 PCS score was avoidance behavior. CONCLUSIONS Our findings largely confirmed the logic model underlying the development of CBT for patients with DS. Interventions could be additionally developed to specifically address beliefs about emotions to assess whether it improves outcomes.
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Affiliation(s)
- T Chalder
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - S Landau
- Department of Biostatistics and Health Informatics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - J Stone
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - A Carson
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - M Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - N Medford
- South London and Maudsley NHS Foundation Trust, London, UK
| | - E J Robinson
- King's College London, School of Population Health and Environmental Sciences, London, UK
- Research Data and Statistics Unit, Royal Marsden Clinical Trials Unit, The Royal Marsden NHS Foundation Trust, Surrey, UK
| | - L H Goldstein
- Department of Psychology, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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van Dijl TL, Videler AC, Aben HP, Kop WJ. Anger regulation in patients with functional neurological disorder: A systematic review. Gen Hosp Psychiatry 2024; 88:30-47. [PMID: 38458028 DOI: 10.1016/j.genhosppsych.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Functional neurological disorder (FND) has been associated with predisposing psychological factors, including dysregulation of anger-related processes. This paper provides a systematic review of the literature on anger regulation in FND. We evaluated anger-related research on patient self-report, observational, and laboratory based measures in FND. The review also addresses adverse childhood experiences and their relation with anger regulation, and the effects of therapies targeting anger regulation in FND. METHODS MEDLINE, EMBASE, and PsycINFO were searched for both quantitative and qualitative research, published in a peer-reviewed journal with a sample size of at least 5 (registered under Prospero protocol CRD42022314340). RESULTS A total of 2200 articles were identified. After screening, 54 studies were included in this review (k = 20 questionnaire-based studies, k = 12 laboratory studies, k = 21 using other methods, and k = 1 used both questionnaires and other methods) representing data of 2502 patients with FND. Questionnaire-based studies indicated elevated levels of state anger and trait hostility in patients with FND. Laboratory studies showed a higher tendency to avoid social threat cues, attentional bias towards angry faces, difficulties reliving anger, and preoccupation with frustrating barriers among FND patients versus controls. No specific childhood experiences were identified related to anger regulation in FND, and too few small and uncontrolled studies were available (k = 2) to assess the effects of anger-related interventions in FND. The overall quality of the studies was fair (k = 31) to poor (k = 18). Five studies (k = 5) were rated as having a good quality. CONCLUSIONS This review suggests that patients with FND have maladaptive anger regulation compared to individuals without FND. The findings also highlight the need for further research on the prevalence and consequences of anger-related processes in the development, diagnosis and treatment of FND.
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Affiliation(s)
- T L van Dijl
- Department of Medical and Clinical Psychology, Center for Research on Psychological Disorders and Somatic Diseases, Tilburg University, Tilburg, the Netherlands; Clinical Centre of Excellence for Body, Mind, and Health, GGz Breburg, Tilburg, the Netherlands; Department Tranzo, Tilburg University, Tilburg, the Netherlands; Department of Psychiatry, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Child and Adolescent Psychiatry, De Hoop ggz, Dordrecht, the Netherlands.
| | - A C Videler
- Clinical Centre of Excellence for Body, Mind, and Health, GGz Breburg, Tilburg, the Netherlands; Department Tranzo, Tilburg University, Tilburg, the Netherlands
| | - H P Aben
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - W J Kop
- Department of Medical and Clinical Psychology, Center for Research on Psychological Disorders and Somatic Diseases, Tilburg University, Tilburg, the Netherlands; Department Tranzo, Tilburg University, Tilburg, the Netherlands
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Berg L, Pringsheim TM, Lerario M, Martino D. Psychological Factors Associated with Functional Tic-like Behaviours during the COVID-19 Pandemic. Res Child Adolesc Psychopathol 2024:10.1007/s10802-024-01184-y. [PMID: 38427218 DOI: 10.1007/s10802-024-01184-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
Functional tic-like behaviours (FTLB) are a female predominant functional neurological disorder that escalated in incidence during the SARS CoV2 pandemic. This study compared social and adaptive functioning, social media use, pandemic experiences, and psychiatric comorbidities between FTLB (n = 35), Tourette Syndrome (TS) (n = 22), and neurotypical (NT) (n = 25) participants ages 11 to 25 years. The psychiatric comorbidity burden for participants with FTLB was formidable, with frequencies ranging from 1.5 to 10 times higher for major depressive disorder and panic disorder compared to TS and NT participants. Borderline personality disorder (BPD), agoraphobia, social anxiety disorder, and generalized anxiety disorder were also significantly more common in FTLB compared to NT participants. Vulnerable attachment scores, social phobia and social interaction anxiety symptoms were higher in participants with FTLB than NT but not TS. Overall distress tolerance, resilient coping, suggestibility, hours on social media, and exposure to tic and TS content were not significantly different between groups. FTLB participants rated their mental health declined more severely during the pandemic than both TS and NT participants and were more likely to experience trouble sleeping, loneliness, and difficulty affording housing and food than NT participants. Participants with FTLB were significantly more likely to identify as gender minority people than TS and NT, though there were no significant differences based on gender identity in the study variables within the FTLB group. The association and potential pathways explaining how psychiatric disorders may be contributing to FTLB, and why certain groups appear at particular risk are discussed.
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Affiliation(s)
- Lindsay Berg
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Tamara M Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | | | - Davide Martino
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
- Mathison Centre for Mental Health Research and Education, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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Staton A, Dawson D, Merdian H, Tickle A, Walker T. Functional neurological disorder: A qualitative study exploring individuals' experiences of psychological services. Psychol Psychother 2024; 97:138-156. [PMID: 37800641 DOI: 10.1111/papt.12504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES Individuals with a diagnosis of FND report experiencing stigma in medical settings, however, there is a paucity of research exploring their experiences in psychological services. The aim of this research was to explore experiences of accessing UK psychological services, from the perspective of those with FND. METHODS This study utilised a qualitative approach with data collected from semi-structured interviews (n = 15) and analysed using reflexive thematic analysis. RESULTS One superordinate theme, 'the stigmatised self within the therapeutic relationship', and five interrelated subthemes were identified: 'internalised stigma and self-doubt', 'selective disclosure to professionals', 'perceptions of psychological explanations', 'having to educate the professionals' and 'attunement and trust within the therapeutic relationship'. Positive therapeutic relationships were perceived to mitigate the impact of these perceived barriers. The conceptualisation of FND and the perception of how this was responded to by services and professionals was a central tenet throughout the related themes. CONCLUSIONS Intra-personal, interpersonal and organisational stigma impact access and engagement to psychological treatment. The findings of this study highlight the need for increased training provision for practitioners with a focus on actively challenging FND stigma within services at both an individual and systemic level.
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Affiliation(s)
- Amelia Staton
- University of Nottingham, Nottingham, UK
- University of Lincoln, Lincoln, UK
| | | | | | | | - Tammy Walker
- Defence Medical Rehabilitation Centre, Loughborough, UK
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Lerario MP, Rosendale N, Waugh JL, Turban J, Maschi T. Functional Neurological Disorder Among Sexual and Gender Minority People. Neurol Clin 2023; 41:759-781. [PMID: 37775203 DOI: 10.1016/j.ncl.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Sexual and gender minority (SGM) people can face unique stressors and structural discrimination that result in higher rates of neuropsychiatric symptoms, such as depression, anxiety, and suicidality. Although more rigorous studies are needed, emerging data suggest a possible higher prevalence of functional neurological disorder and other brain-mind-body conditions in SGM people. Representation and iterative feedback from affected community members is critical to the process of developing affirming environments. More research is needed to explore the relevance of functional neurologic disorder in SGM people within a biopsychosocial framework.
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Affiliation(s)
- Mackenzie P Lerario
- Fordham Graduate School of Social Service, New York, NY, USA; Greenburgh Pride, Greenburgh, NY, USA.
| | - Nicole Rosendale
- Department of Neurology, University of California San Francisco; Weill Institute for Neurosciences, University of California San Francisco
| | - Jeff L Waugh
- Department of Pediatrics, UT Southwestern Medical School, Dallas, TX, USA
| | - Jack Turban
- Division of Child & Adolescent Psychiatry, University of California San Francisco
| | - Tina Maschi
- Fordham Graduate School of Social Service, New York, NY, USA; Greenburgh Pride, Greenburgh, NY, USA
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Roberts NA, Villarreal LD, Burleson MH. Socioemotional self- and co-regulation in functional seizures: comparing high and low posttraumatic stress. Front Psychiatry 2023; 14:1135590. [PMID: 37255682 PMCID: PMC10225681 DOI: 10.3389/fpsyt.2023.1135590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 04/13/2023] [Indexed: 06/01/2023] Open
Abstract
Functional seizures (FS) are seizure-like symptoms without electroencephalogram (EEG)-based epileptic activity. Those with FS often show emotion-related dysfunction and disrupted interpersonal relationships, in which posttraumatic stress disorder symptoms (PTS) may play a role. We sought to better understand trauma comorbidities and socioemotional processes in FS, including affectionate touch, a form of social connection linked to emotion regulation and awareness. We administered questionnaires online to a community sample of 89 trauma-exposed FS participants (FS diagnoses were self-reported), 51 with and 38 without clinical-level PTS (FS-PTShi, FS-PTSlo) and 216 seizure-free matched trauma-exposed controls (TCs), 91 with and 125 without clinical-level PTS (TC-PTShi, TC-PTSlo) per the Posttraumatic Stress Disorder Symptom Checklist (PCL). As hypothesized, both FS-PTShi and FS-PTSlo reported more emotional avoidance (Brief Experiential Avoidance Questionnaire), more emotion regulation difficulties (Difficulties in Emotion Regulation Scale), and more perceived stress (Perceived Stress Scale) than PTS-matched counterparts. FS-PTShi also reported less reappraisal (Emotion Regulation Questionnaire), more loneliness (UCLA Loneliness Scale), and less frequent affectionate touch (Physical Affection Scale) during waking and surrounding sleep than TC-PTShi, whereas FS-PTSlo and TC-PTSlo did not differ. Neither FS group differed from PTS-matched controls in emotion suppression (Emotion Regulation Questionnaire) or comfort with social touch (Social Touch Questionnaire). Among FS, FS-PTShi reported more difficulties than FS-PTSlo on nearly all measures (non-significant trend for social support). Findings underscore potential synergistic effects of FS and PTS clinical symptoms in shaping experiences of one's emotions and social world, suggesting fostering meaningful connections with others, including via affectionate touch, is an important treatment target.
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Milano BA, Moutoussis M, Convertino L. The neurobiology of functional neurological disorders characterised by impaired awareness. Front Psychiatry 2023; 14:1122865. [PMID: 37009094 PMCID: PMC10060839 DOI: 10.3389/fpsyt.2023.1122865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.
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Affiliation(s)
- Beatrice Annunziata Milano
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
- Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michael Moutoussis
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
| | - Laura Convertino
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom
- *Correspondence: Laura Convertino,
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Zarotti N, Poz R, Fisher P. Compassion-Focused Therapy for an Older Adult with Motor Functional Neurological Disorder: A Case Study. Clin Gerontol 2022; 46:457-466. [PMID: 36205929 DOI: 10.1080/07317115.2022.2130124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Motor functional neurological disorder (mFND) is a condition where individuals may experience difficulties such as tremors, gait impairments, and paralysis which are not explained by identified structural damage to the brain. Studies on chronic conditions have suggested that psychological interventions such as compassion-focused therapy (CFT) may be effective in improving well-being in people with mFND. However, no evidence is currently available on psychotherapy for older people with mFND. METHODS A 12-session CFT intervention was delivered to an 81-year-old British male with mFND. Standardized measures were administered at baseline and post-intervention. RESULTS At post-intervention, a 30% decrease in perceived psychological impact of mFND was found, along with clinically significant changes in anxiety and depression. Good levels of feasibility and acceptability were also observed. CONCLUSIONS To our knowledge, this is the first evidence of the feasibility, acceptability, and potential effectiveness of CFT for psychological difficulties linked with mFND, as well as the first evidence for any psychotherapy with an older adult with mFND. CLINICAL IMPLICATIONS CFT shows the potential to be effective, feasible, and acceptable for treating difficulties linked with mFND in older people. However, further high-quality investigations based on experimental designs are needed to build on the present preliminary findings.
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Affiliation(s)
- Nicolò Zarotti
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Rebecca Poz
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK.,West Suffolk Older People's Services, Norfolk and Suffolk NHS Foundation Trust, Bury St Edmunds, UK
| | - Paul Fisher
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
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