The clinical management of functional neurological disorder: A scoping review of the literature

OBJECTIVE

To date, there have been no reviews bringing together evidence on the clinical management of functional neurological disorder (FND) and patients', caregivers', and healthcare workers' experiences. This review provides an overview of the literature focused on the clinical management of FND.

METHODS

Four databases were searched, and a consultation exercise was conducted to retrieve relevant records dated from September 2010 to September 2020. Articles documenting diagnostic methods, treatments or interventions, or the experiences and perspectives of patients and healthcare workers in the clinical management of FND were included.

RESULTS

In total, 2756 records were retrieved, with 162 included in this review. The diagnostic methods reported predominantly included positive clinical signs, v-EEG and EEG. Psychological treatments and medication were the most reported treatments. Mixed findings of the effectiveness of CBT were found. Haloperidol, physiotherapy and scripted diagnosis were found to be effective in reducing FND symptoms. Several facilitators and barriers for patients accessing treatment for FND were reported.

CONCLUSION

The literature describing the clinical management for FND has increased considerably in recent times. A wide variety of diagnostic tools and treatments and interventions were found, with more focus being placed on tests that confirm a diagnosis than 'rule-out' tests. The main treatment type found in this review was medication. This review revealed that there is a lack of high-quality evidence and reflects the need for official clinical guidelines for FND, providing healthcare workers and patients the support needed to navigate the process to diagnose and manage FND.

Mindfulness Meditation Leads To Increased Dispositional Mindfulness And Interoceptive Awareness Linked To A Reduced Dissociative Tendency

Dissociation is an involuntary defensive mechanism to protect oneself by avoiding unbearable internal conflicts or overwhelming emotions. Cultivating mindful awareness could allow the development of voluntary processes that can offer part of the self-protective function of dissociation while favoring internal integration processes. The aim of the present study was to explore the effects of a 7-week Mindfulness Oriented Meditation (MOM) training on healthy individuals' self-reported dissociative experience, mindfulness skills and interoceptive awareness. After the training, in comparison to a waiting-list control group (N = 102), the MOM group (N = 110) showed reduced dissociative tendencies (p < .05), increased dispositional mindfulness (p < .001) and increased interoceptive awareness (in the aspects of not-worrying, self-regulation and body listening; p < .001). Moreover, correlational evidence showed that the more MOM participants increased in mindfulness skills after the training the more they reported increased interoceptive awareness and decreased dissociative functioning (p < .05). Mindfulness skills also improved with more home meditation practice executed by MOM participants (p < .05). These findings were attributed to a possible role of mindfulness meditation in enabling the development of volitional processes that afford psychological safety and integration, in contrast with the involuntary nature of dissociation.

Coping Motivated Alcohol Use: The Role of Social Anxiety and Dissociation

Background: Social anxiety has been associated with higher rates of negative alcohol use consequences, and this relationship appears to be accounted for by coping drinking motives. Dissociation is commonly present in anxiety disorders, including social anxiety disorder, and may serve to unconsciously reduce negative emotions when more effortful coping strategies are not effective. Objectives: The present study examined whether the relationship between social anxiety, coping motives, and alcohol consequences was moderated by dissociative symptoms. It was hypothesized that coping motives would mediate the relationship between social anxiety and alcohol consequences, and that dissociation would moderate the relationship between social anxiety and coping motives. Undergraduate students who endorsed alcohol use within the past 30 days (n = 320) were recruited from a large public university. Participants completed measures of social anxiety, dissociation, alcohol motives, and alcohol consequences as part of a larger online questionnaire. Results: Coping motives were found to mediate the relationship between social anxiety and alcohol consequences. Dissociation did not moderate the relationship between social anxiety and coping motives. Dissociation was significantly associated with alcohol consequences via coping motives. Conclusions: Future research should include longitudinal research designs or ecological momentary assessment designs and should examine these relationships in clinical and community samples.

Psychological inflexibility and somatization in nonepileptic attack disorder

BACKGROUND

There is no clear understanding of what causes and maintains nonepileptic attack (NEA) disorder (NEAD), or which psychological therapies may be helpful. The relationships between variables of psychological inflexibility: experiential avoidance (EA), cognitive fusion (CF), mindfulness, and key outcome variables in NEAD: somatization, impact upon life, and NEA frequency were investigated.

METHOD

Two hundred eighty-five individuals with NEAD completed validated measures online. Linear regression was used to explore which variables predicted somatization and impact upon life. Ordinal regression was used to explore variables of interest in regard to NEA frequency.

RESULTS

Mindfulness, EA, CF, somatization, and impact upon life were all significantly correlated. Mindfulness uniquely predicted somatization when considered in a model with EA and CF. Higher levels of somatization increased the odds of experiencing more NEAs. Individuals who perceived NEAD as having a more significant impact upon their lives had more NEAs, more somatic complaints, and more EA.

CONCLUSIONS

Higher levels of CF and EA appear to be related to lower levels of mindfulness. Lower levels of mindfulness predicted greater levels of somatization, and somatization predicted NEA frequency. Interventions that tackle avoidance and increase mindfulness, such as, acceptance and commitment therapy, may be beneficial for individuals with NEAD. Future directions for research are suggested as the results indicate more research is needed.

Neurocognitive functioning in patients with conversion disorder/functional neurological disorder

Neurocognitive symptoms are common in individuals with somatic symptom and related disorders (SSRD), but little is known about the specific impairments in neurocognitive domains in patients with conversion disorder (CD)/functional neurological disorder (FND). This study examines neurocognitive functioning in patients with CD/FND compared to patients with other SSRD. The sample consisted of 318 patients. Twenty‐nine patients were diagnosed with CD/FND, mean age 42.4, standard deviation (SD) = 13.8 years, 79.3% women, and 289 patients had other SSRD (mean age 42.1, SD = 13.3, 60.2% women). Patients completed a neuropsychological test battery that addressed a broad range of neurocognitive domains, including information processing speed, attention and executive functioning. Patients with CD/FND had clinically significant neurocognitive deficits in all neurocognitive domains based on normative data comparison. Patients with CD/FND also performed significantly worse than patients with other SSRD on information processing speed (Digit Symbol Substitution Test (V = .115, p = .035), Stroop Color–Word Test (SCWT) card 1 (V = .190, p = .006), and SCWT card 2 (V = .244, p < .001). No CD/FND vs. other SSRD differences were observed in other neurocognitive domains. These findings indicate the patients with CD/FND perform worse on information processing speed tests compared to patients with other SSRD.

Avoidance in nonepileptic attack disorder: A systematic review and meta-analyses

BACKGROUND

Avoidance is the active process of trying to escape from or not experience situations, places, thoughts, or feelings. This can be done through behavioral or cognitive strategies, or more broadly, a combination of both, utilized in an attempt to disengage from private experiences referred to as experiential avoidance (EA). Avoidance is considered important in the development and maintenance of nonepileptic attack disorder (NEAD). This review aimed to understand avoidance in NEAD and evaluate its role as a contributory factor.

METHODS

Fourteen articles were identified by searching Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE Complete, PsycINFO, and EMBASE and were combined in a narrative synthesis. Six of these articles were included in a meta-analysis comparing levels of EA for individuals with NEAD and healthy controls (HC), and four were included in a meta-analysis comparing EA in NEAD to epilepsy comparisons (EC).

CONCLUSIONS

Experiential avoidance appears to be a strategy that is used by a high proportion of the population with NEAD. The group with NEAD utilized significantly more avoidance compared with both the HC and EC. However, further research is needed to understand the extent and types of avoidance that are relevant.

The effectiveness and acceptability of a guided self-help Acceptance and Commitment Therapy (ACT) intervention for psychogenic nonepileptic seizures

This study utilized a nonconcurrent case-series design to examine the effectiveness and acceptability of a guided self-help Acceptance and Commitment Therapy (ACT) intervention for people with psychogenic nonepileptic seizures. A key aim of the study was to investigate the relationship between psychological flexibility (a key process within ACT), psychological health, quality of life, and seizure frequency. Six participants completed the study, with reliable and clinically significant changes in psychological flexibility, quality of life, and psychological health observed in the majority of participants. Notable reductions in self-reported seizure frequency were also observed. The implications of these findings for clinical practice are discussed and recommendations for future research suggested.

Conversion Disorder (Functional Neurological Symptom Disorder) in Primary Care Mental Health

This case report describes the application of a dialectical behavioral therapy–informed psychotherapy approach to treating conversion disorder (functional neurological symptom disorder) with motor dysfunction in a Veterans Administration Health System Primary Care–Mental Health Integration Clinic. “Jane,” a 30-year-old veteran, was diagnosed with conversion disorder, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD). She completed 25 sessions of treatment focused on improving emotion regulation and interpersonal skills over an 8-month period. At the end of treatment, Jane demonstrated improved motor ability and clinically significant improvements in her reported symptoms of MDD (per the Patient Health Questionnaire–9) and PTSD (per the PTSD Checklist–Civilian Version). This case report supports the conceptualization of conversion disorder as a function of emotion dysregulation and the application of a dialectical behavior therapy–informed treatment approach.

Retreating From Life: The Boy Whose Body Experienced His Pain

The expression of psychological distress through somatic symptoms is most prevalent among children. Somatic symptom disorders represent a difficult category of disorders to treat and they are often misdiagnosed due to their physical symptomology and dismissed due to their malingering stigma. The current case report follows the treatment of David, a 10-year-old Caucasian male, admitted into the pediatric psychiatric ward of a general hospital, uncommunicative, showing little signs of responsiveness, and dependent on nursing staff for basic needs. Following a complex treatment protocol which integrated key elements of psychodynamic and cognitive-behavior (CBT) treatment recommendations for somatic disorders, David was discharged after 6 months as an inpatient. This in-depth case study provides a synthesis of the varied research on somatic symptom disorders and an acute understanding of how to combine the understanding of complex family dynamics and individual personality structure with empirically reinforced treatment strategies.

Prolonged Exposure Therapy for Comorbid Psychogenic Nonepileptic Seizures and Posttraumatic Stress Disorder

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures but are not associated with epileptic discharges in the brain. Instead, these episodes, which tend to occur with alterations in consciousness and body movements, are thought to be the result of mechanisms of conversion and dissociation. Psychological trauma and PTSD are very prevalent among patients with PNES. PNES can be conceived of as an extreme avoidance mechanism that serves the function of modulating distress and, in some cases, eliminating the precipitant stressor. Avoidance is also an essential component of PTSD. In patients who carry a dual diagnosis of PNES and PTSD, it is sensible that an empirically validated treatment for PTSD such as prolonged exposure (PE) therapy which targets avoidance by promoting exposure might be a useful approach to treat these patients. In this report, we present the case of a 52-year-old male with a 7-year history of PNES. His seizures, which were characterized by intense body shaking and loud guttural outbursts, were occurring up to 15 times per day. Because of these symptoms, he lost his employment and was ostracized by his family. Upon completion of a course of intensive outpatient PE, he achieved full remission of all psychogenic symptoms. Except for three brief seizures, he has maintained his health for 2 years. This constitutes the first detailed report of PE therapy used to effectively treat comorbid PNES and posttraumatic stress symptoms.

Treating functional non-epileptic attacks - Should we consider acceptance and commitment therapy?

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.

Using Acceptance and Commitment Therapy to Improve Outcomes in Functional Movement Disorders: A Case Study

Although there are many theories of functional movement disorders (FMD), the causes and prognosis remain unclear, and there are no treatments with high-quality empirical support. Acceptance and commitment therapy (ACT) is an acceptance-based behavior therapy which, via altering a process called psychological flexibility, aims to support behaviors that are consistent with a person’s overarching values—even in difficult, uncertain, or immutable contexts. It may, therefore, have pragmatic benefits in the context of FMD. We outline the theoretical basis for ACT and detail a case study of a brief (six session) intervention for increasing personally meaningful activity with FMD. The participant was in her early 20s and had been diagnosed with functional propriospinal myoclonus. ACT techniques including relational framing, defusion, and mindfulness exercises were used to increase psychological flexibility, with the goal of enabling effective functioning within the difficult context created by FMD. Following treatment, the participant showed a reliable change/clinical recovery in psychological flexibility (Acceptance and Action Questionnaire II [AAQ-II]), FMD symptom interference (Work and Social Adjustment Scale [WSAS]; primary outcome), and mood (Clinical Outcomes in Routine Evaluation 10-item scale [CORE-10]; secondary outcome). This case study demonstrates an approach that focuses first on improving functioning with FMD, as opposed to eliminating or controlling symptoms.

Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD)

OBJECTIVE

Although there is general consensus that psychogenic non-epileptic seizures (PNES) are treated with psychotherapy, the effectiveness of most psychotherapeutic modalities remains understudied. In this treatment series of 16 patients dually diagnosed with PNES and post-traumatic stress disorder (PTSD), we evaluated the effect of prolonged exposure therapy (PE) on reduction of PNES. Secondary measures included Beck Depression Inventory (BDI-II) and Post-Traumatic Disorder Diagnostic Scale (PDS).

METHODS

Subjects diagnosed with video EEG-confirmed PNES and PTSD confirmed through neuropsychological testing and clinical interview were treated with traditional PE psychotherapy with certain modifications for the PNES. Treatment was conducted over the course of 12-15 weekly sessions. Seizure frequency was noted in each session by examining the patients' seizure logs, and mood and PTSD symptomatology was assessed at baseline and on the final session.

RESULTS

Eighteen subjects enrolled, and 16 (88.8%) completed the course of treatment. Thirteen of the 16 (81.25%) therapy completers reported no seizures by their final PE session, and the other three reported a decline in seizure frequency (Z=-3.233, p=0.001). Mean scores on scales of depression (M=-13.56, SD=12.27; t (15)=-4.420, p<0,001) and PTSD symptoms (M=-17.1875, SD=13.01; t (15)=-5.281, p<0.001) showed significant improvement from baseline to final session. Longitudinal seizure follow up in 14 patients revealed that gains made on the final session were maintained at follow-up (Z=-1.069 p=0.285).

SIGNIFICANCE

Prolonged exposure therapy for patients dually diagnosed with PNES and PTSD reduced the number of PNES and improved mood and post traumatic symptomatology. Follow-up revealed that gains made in seizure control on the last day of treatment were maintained over time.

Role of mindfulness in dissociative disorders among adolescents

CONTEXT

Dissociation is understood as maladaptive coping and is common in children and adolescents. Treatment outcome studies show improvement in comorbid conditions suggesting the need to implement programs that target dissociative pathology.

AIM

To study the effect of practicing mindfulness among adolescents diagnosed with dissociative disorders.

SETTINGS AND DESIGN

It was a hospital-based repeated measures design.

MATERIALS AND METHODS

7 adolescents participated in a mindfulness-based therapeutic program for 6 weeks.

STATISTICAL ANALYSIS

Scores were expressed as mean ± standard deviation. Friedman test was used to assess significance of the difference in scores at various assessment phases. Wilcoxon signed rank test was used for post hoc analysis.

RESULTS

Participants were mostly female adolescents from rural, Eastern India. There was a significant reduction in dissociative experiences and significant improvement in mindfulness.

CONCLUSIONS

Incorporating mindfulness in clinical practice may prove effective in reducing dissociation and promoting adaptive functioning.

Treatment of psychogenic nonepileptic seizures: updated review and findings from a mindfulness-based intervention case series

Psychogenic nonepileptic seizures (PNES) were first described in the medical literature in the 19th century, as seizure-like attacks not related to an identified central nervous system lesion, and are currently classified as a conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). While a universally accepted and unifying etiological model does not yet exist, several risk factors have been identified. Management of PNES should be based on interdisciplinary collaboration, targeting modifiable risk factors. The first treatment phase in PNES is patient engagement, which is challenging given the demonstrated low rates of treatment retention. Acute interventions constitute the next phase in treatment, and most research studies focus on short-term evidence-based interventions. Randomized controlled pilot trials support cognitive-behavioral therapy. Other psychotherapeutic and psychopharmacological interventions have been less well-studied using controlled and uncontrolled trials. Within the discussion of acute interventions, we present a preliminary evaluation for feasibility of a mindfulness-based psychotherapy protocol in a very small sample of PNES patients. We demonstrated in 6 subjects that this intervention is feasible in real-life clinical scenarios and warrants further investigation in larger scale studies. The final treatment phase is long-term follow-up. Long-term outcome studies in PNES show that a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality. We believe that PNES should be understood as a disease that requires different types of intervention during the various phases of treatment.

Anxiety and avoidance in psychogenic nonepileptic seizures: the role of implicit and explicit anxiety

This study examined implicit and explicit anxiety in individuals with epilepsy and psychogenic nonepileptic seizures (PNESs) and explored whether these constructs were related to experiential avoidance and seizure frequency. Based on recent psychological models of PNESs, it was hypothesized that nonepileptic seizures would be associated with implicit and explicit anxiety and experiential avoidance. Explicit anxiety was measured by the State-Trait Anxiety Inventory; implicit anxiety was measured by an Implicit Relational Assessment Procedure; and experiential avoidance was measured with the Multidimensional Experiential Avoidance Questionnaire. Although both groups with epilepsy and PNESs scored similarly on implicit measures of anxiety, significant implicit-explicit anxiety discrepancies were only identified in patients with PNESs (p<.001). In the group with PNESs (but not in the group with epilepsy), explicit anxiety correlated with experiential avoidance (r=.63, p<.01) and frequency of seizures (r=.67, p<.01); implicit anxiety correlated with frequency of seizures only (r=.56, p<.01). Our findings demonstrate the role of implicit anxiety in PNESs and provide additional support for the contribution of explicit anxiety and experiential avoidance to this disorder.

Dissociative disorders in medical settings

Despite the challenges of conducting research on dissociation and the dissociative disorders, our understanding has grown greatly over the past three decades, including our knowledge of the often overlooked sensorimotor manifestations of dissociation, more commonly referred to as somatoform dissociation. This article will first review the definitions and presentations of dissociation in general along with recent research on the concept of somatoform dissociation. Then, each of the dissociative disorders and conversion disorder will be discussed in further detail as well as how they might present in a medical setting. Current recommendations for diagnosis and treatment will also be provided.

An update on psychogenic movement disorders

Psychogenic movement disorders (PMD) and other conversion disorders (CD) with apparent neurologic signs (neurologic CD) plague patients and perplex physicians. Due to a lack of objective evidence of underlying brain lesions, CD were largely abandoned by neurologists and remained poorly understood psychiatric diagnoses throughout most of the 20th century. Modern neuroscience now supports increasingly comprehensive biological models for these complex disorders, definitively establishing their place in both neurology and psychiatry. Although it is often clinically useful to distinguish a movement disorder as either "organic" or "psychogenic," this dichotomy is difficult to defend scientifically. Here we describe the neuroimaging and neurophysiologic evidence for dysfunctional neural networks in PMD, explain the diagnostic potential of clinical neurophysiologic testing, discuss the promising if increasingly complex role of neuropsychiatric genetics, and review current treatment strategies.