How does cognitive behavior therapy for dissociative seizures work? A mediation analysis of the CODES trial

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.

Haemonchus contortus: an overview

This focus article was prepared by Amanda Carson, Rudolf Reichel, Suzie Bell, Rachael Collins and Jasmine Smith of the APHA Small Ruminant Species Expert Group, and Dave Bartley from the Moredun Research Institute.

Managing liver fluke on hill farms

This focus article has been prepared by Amanda Carson and Bryony Jones of the APHA Small Ruminant Expert Group and Dai Grove-White of the University of Liverpool.

Moderators of cognitive behavioural therapy treatment effects and predictors of outcome in the CODES randomised controlled trial for adults with dissociative seizures

OBJECTIVE

We explored moderators of cognitive behavioural therapy (CBT) treatment effects and predictors of outcome at 12-month follow-up in the CODES Trial (N = 368) comparing CBT plus standardised medical care (SMC) vs SMC-alone for dissociative seizures (DS).

METHODS

We undertook moderator analyses of baseline characteristics to determine who had benefited from being offered CBT 12 months post-randomisation. Outcomes included: monthly DS frequency, psychosocial functioning (Work and Social Adjustment Scale - WSAS), and health-related quality of life (Mental Component Summary (MCS) and Physical Component Summary (PCS) SF-12v2 scores). When moderating effects were absent, we tested whether baseline variables predicted change irrespective of treatment allocation.

RESULTS

Moderator analyses revealed greater benefits (p < 0.05) of CBT on DS frequency for participants with more (≥22) symptoms (Modified PHQ-15) or ≥ 1 current (M.I.N.I.-confirmed) comorbid psychiatric diagnosis at baseline. The effect of CBT on PCS scores was moderated by gender; women did better than men in the CBT + SMC group. Predictors of improved outcome included: not receiving disability benefits, lower anxiety and/or depression scores (PCS, MCS, WSAS); shorter duration, younger age at DS onset, employment, fewer symptoms and higher educational qualification (PCS, WSAS); stronger belief in the diagnosis and in CBT as a "logical" treatment (MCS). Some variables that clinically might be expected to moderate/predict outcome (e.g., maladaptive personality traits, confidence in treatment) were not shown to be relevant.

CONCLUSION

Patient complexity interacted with treatment. CBT was more likely to reduce DS frequency in those with greater comorbidity. Other patient characteristics predicted outcome regardless of the received intervention.

Watery mouth disease in lambs

This focus article has prepared by Rachael Collins and Amanda Carson of the APHA Small Ruminant Expert Group.

APHA thin ewe investigation project

This focus article has been prepared by Suzi Bell, Amanda Carson, Rachael Collins, Lizzy Dunnett, Rudolf Reichel and Moyna Richey of the APHA Small Ruminant Expert Group.

Novel Picornavirus in Lambs with Severe Encephalomyelitis

Using metagenomic analysis, we identified a novel picornavirus in young preweaned lambs with neurologic signs associated with severe nonsuppurative encephalitis and sensory ganglionitis in 2016 and 2017 in the United Kingdom. In situ hybridization demonstrated intralesional neuronotropism of this virus, which was also detected in archived samples of similarly affected lambs (1998–2014).

First Case of Idiopathic Eosinophilic Meningoencephalitis in a Sheep

A 1.5-year-old ewe was presented with neurological signs that had been observed from about 2 days prior to death. There had been no clinical response to anti-inflammatory and antibiotic treatment. Histopathological examination of the brain revealed a severe and widespread eosinophilic meningoencephalomyelitis of unknown aetiology. Defining histological features included diffuse angiocentric eosinophilic infiltrates in the neuroparenchyma and meninges, neuronal necrosis, astrocytosis, neuropil vacuolation and occasional glial scars. Differential diagnostics for eosinophilic meningoencephalitis were taken into account and investigated by means of special stains, immunohistochemistry, bacteriology and polymerase chain reaction. No pathological changes or ancillary tests were supportive or revealed a specific aetiology for the condition and therefore it was considered idiopathic. Idiopathic meningoencephalitis is a rare disease, mainly described in man and rarely in dogs, with no apparent aetiological cause or potential breed predisposition. To our knowledge this is the first case of idiopathic eosinophilic meningoencephalitis in a sheep and provides a histopathological guideline for prospective comparative pathology studies.

Mediators and moderators of change in mindfulness-based stress reduction for painful diabetic peripheral neuropathy

Painful diabetic peripheral neuropathy (PDPN) is a chronic pain condition with modest response to pharmacotherapy. Participation in mindfulness-based stress reduction (MBSR) leads to improvements in pain-related outcomes but the mechanisms of change are unknown. The present study examined the mediators and moderators of change in 62 patients with PDPN who participated in a randomized controlled trial comparing MBSR to waitlist. Changes in mindfulness and pain catastrophizing were tested simultaneously as mediators. Increased mindfulness mediated the association between participation in MBSR and improved pain severity, pain interference, and the physical component of health-related quality of life (HRQoL) 3 months later. The mediation effect of pain catastrophizing was not significant. Linear moderated trends were also found. Post-hoc moderated mediation analyses suggested that MBSR patients with longer histories of diabetes might increase their mindfulness levels more, which in turn leads to improved pain severity and physical HRQoL. These results allow for a deeper understanding of pathways by which MBSR benefits patients with PDPN.

Survey to determine the farm-level impact of Schmallenberg virus during the 2016-2017 United Kingdom lambing season

Schmallenberg virus (SBV) causes abortions, stillbirths and fetal malformations in naïve ruminants. The impact of the initial outbreak (2011/2012) on British sheep farms has been previously investigated, with higher farmer perceived impacts and increased lamb and ewe mortality reported on SBV-affected farms. After several years of low, or no, circulation the UK sheep flock once again became vulnerable to SBV infection. Re-emergence was confirmed in autumn 2016. This study reports the analysis of a questionnaire designed to determine the farm-level impact of SBV on the 2016/2017 UK lambing period. Higher neonatal lamb mortality, dystocia and associated ewe deaths, and higher perceived impacts on sheep welfare, flock financial performance and farmer emotional wellness were reported on SBV confirmed (n=59) and SBV suspected (n=82), than SBV not suspected (n=74) farms. Additionally, although few farmers (20.4 per cent) reported previously vaccinating against SBV, the majority (78.3 per cent) stated they would vaccinate if purchasing at less than £1 per dose. These results are largely comparable to the findings reported for the 2011/2012 outbreak, highlighting the ongoing impact of SBV on sheep farms. If SBV continues to re-emerge cyclically, the economic and animal welfare costs to the UK sheep farming industry will continue.

Post-admission outcomes of participants in the PARAMEDIC trial: A cluster randomised trial of mechanical or manual chest compressions

BACKGROUND

The PARAMEDIC cluster randomised trial evaluated the LUCAS mechanical chest compression device, and did not find evidence that use of mechanical chest compression led to an improvement in survival at 30 days. This paper reports patient outcomes from admission to hospital to 12 months after randomisation.

METHODS

Information about hospital length of stay and intensive care management was obtained through linkage with Hospital Episode Statistics and the Intensive Care National Audit and Research Centre. Patients surviving to hospital discharge were approached to complete questionnaires (SF-12v2, EQ-5D, MMSE, HADS and PTSD-CL) at 90days and 12 months. The study is registered with Current Controlled Trials, number ISRCTN08233942.

RESULTS

377 patients in the LUCAS arm and 658 patients in the manual chest compression were admitted to hospital. Hospital and intensive care length of stay were similar. Long term follow-up assessments were limited by poor response rates (53.7% at 3 months and 55.6% at 12 months). Follow-up rates were lower in those with worse neurological function. Among respondents, long term health related quality of life outcomes and emotional well-being was similar between groups. Cognitive function, measured by MMSE, was marginally lower in the LUCAS arm mean 26.9 (SD 3.7) compared to control mean 28.0 (SD 2.3), adjusted mean difference -1.5 (95% CI -2.6 to -0.4).

CONCLUSION

There were no clinically important differences identified in outcomes at long term follow-up between those allocated to the mechanical chest compression compared to those receiving manual chest compression.

Epidemiology

The epidemiology of functional neurologic disorders (FND) is complex and has been hampered over the years by a lack of clear definition, with previous definitions struggling with an uneasy mix of both physical and psychologic components. The recent changes in DSM-5 to a definition based on positive identification of physical symptoms which are incongruent and inconsistent with neurologic disease and the lack of need for any associated psychopathology represent a significant step forward in clarifying the disorder. On this basis, FND account for approximately 6% of neurology outpatient contacts and putative community incidence rates of 4-12 per 100 000 per annum. Comorbid neurologic disease occurs in around 10% of cases. The diagnosis is reliable, with revision rates less than 5%. Of note, this revision rate was consistent prior to the widespread utilization of computed tomography and magnetic resonance imaging. FND symptoms are disabling and associated with significant distress. They are more common in women and have a peak incidence between the ages of 35 and 50; however the presentation is common in men and throughout the lifespan. The issues surrounding case definition, ascertainment, misdiagnosis, and risk factors are discussed in detail.

Assessment of patients with functional neurologic disorders

We describe an overall approach and structure to the clinical assessment of the patient with a functional neurologic disorder. Whilst the primary purpose of the assessment is to make a diagnosis and develop a treatment plan, we believe the assessment also plays a key role in treatment in its own right, as it sets a tone and context for future clinical interactions. We aim to set up an atmosphere of collaboration based on taking the patient's problems seriously, and emphasizing that all facets of the patient's presentation - physical, psychologic, and social - are of importance. Patients with functional disorders can be perceived as difficult to help and yet with the correct approaches we believe the consultation can be much more satisfying for both patient and doctor. Finally, we discuss and list some of the common diagnostic pitfalls in the assessment of functional neurologic disorders, looking at features that lead to erroneous diagnosis of neurologic disease (such as old age, la belle indifférence, and lack of psychiatric comorbidity) and an erroneous diagnosis of a functional disorder (such as "bizarre" gait in stiff-person syndrome).

Inpatient treatment for functional neurologic disorders

Patients with functional neurologic disorders present to clinicians with a variety of symptomatic manifestations, with various levels of severity, chronicity, and comorbidity, as well as with various degrees of past adversity, intrinsic resilience, and available external support. Clearly, treatment must be individualized. For those patients who have been severely or chronically impaired, especially if adequate prior outpatient treatments have failed, inpatient treatment that integrates the various modalities outlined here provides a rational route of rescue from a course otherwise potentially characterized by protracted dependence and disability. Based on the data currently available, we believe this treatment approach is worthy of further study to refine the component treatment strategies and enhance the potentially most effective ingredients. For patients with severe levels of disability, who could be managed in a multimodal day-treatment program, that approach also warrants further consideration.

Explanation as treatment for functional neurologic disorders

There is widespread agreement that the way health professionals communicate the diagnosis of functional neurologic disorders (FND) has a central role in treatment, as it does arguably for most conditions. In this chapter we discuss barriers to effective diagnosis, different models of explanation and evidence regarding the importance of effective communication of the diagnosis in FND, especially movement disorders, and dissociative (nonepileptic) seizures. Debates and disagreements about how to go about this task often reflect different theoretic models held by health professionals rather than evidence. More evidence is required to know whether an initial emphasis on one model is more or less effective than another (e.g., a functional model vs. a psychologic model). We conclude, however, that there are a number of generic components to effective explanation shared by most authors on the topic that form the basis of a consensus. These include taking the patient seriously, giving the problem a diagnostic label, explaining the rationale for the diagnosis, some discussion of how the symptoms arise, emphasis on the potential for reversibility (rather than damage), and effective triage and referral for other treatment where appropriate. Although explanation can sometimes be therapeutic on its own, its role is probably more important as a facilitator to other therapy, including self-help, physical treatments, and psychotherapy.

Psychologic theories in functional neurologic disorders

In this chapter we review key psychologic theories that have been mooted as possible explanations for the etiology of functional neurologic symptoms, conversion disorder, and hysteria. We cover Freudian psychoanalysis and later object relations and attachment theories, social theories, illness behavior, classic and operant conditioning, social learning theory, self-regulation theory, cognitive-behavioral theories, and mindfulness. Dissociation and modern cognitive neuroscience theories are covered in other chapters in this series and, although of central importance, are omitted from this chapter. Our aim is an overview with the emphasis on breadth of coverage rather than depth.

Managing diabetes in people with dementia

Diabetes and dementia may manifest simultaneously: one is potentially life threatening, the other causes severe, progressive loss of memory and cognitive function. Where they coexist, they present nurses with challenges such as administering life-saving interventions to patients who are unable to give informed consent. This article offers guidance on the clinical and ethical challenges involved in blood glucose monitoring and medicines administration in patients with dementia.

Evidence for the role of EPHX2 gene variants in anorexia nervosa

Anorexia nervosa (AN) and related eating disorders are complex, multifactorial neuropsychiatric conditions with likely rare and common genetic and environmental determinants. To identify genetic variants associated with AN, we pursued a series of sequencing and genotyping studies focusing on the coding regions and upstream sequence of 152 candidate genes in a total of 1205 AN cases and 1948 controls. We identified individual variant associations in the Estrogen Receptor-ß (ESR2) gene, as well as a set of rare and common variants in the Epoxide Hydrolase 2 (EPHX2) gene, in an initial sequencing study of 261 early-onset severe AN cases and 73 controls (P=0.0004). The association of EPHX2 variants was further delineated in: (1) a pooling-based replication study involving an additional 500 AN patients and 500 controls (replication set P=0.00000016); (2) single-locus studies in a cohort of 386 previously genotyped broadly defined AN cases and 295 female population controls from the Bogalusa Heart Study (BHS) and a cohort of 58 individuals with self-reported eating disturbances and 851 controls (combined smallest single locus P<0.01). As EPHX2 is known to influence cholesterol metabolism, and AN is often associated with elevated cholesterol levels, we also investigated the association of EPHX2 variants and longitudinal body mass index (BMI) and cholesterol in BHS female and male subjects (N=229) and found evidence for a modifying effect of a subset of variants on the relationship between cholesterol and BMI (P<0.01). These findings suggest a novel association of gene variants within EPHX2 to susceptibility to AN and provide a foundation for future study of this important yet poorly understood condition.

Genetic distinctiveness of the Herdwick sheep breed and two other locally adapted hill breeds of the UK

There is considerable interest in locally adapted breeds of livestock as reservoirs of genetic diversity that may provide important fitness traits for future use in agriculture. In marginal areas, these animals contribute to food security and extract value from land unsuitable for other systems of farming. In England, close to 50% of the national sheep flock is farmed on grassland designated as disadvantaged areas for agricultural production. Many of these areas are in the uplands, where some native breeds of sheep continue to be commercially farmed only in highly localised geographical regions to which they are adapted. This study focuses on three of these breeds, selected for their adaptation to near identical environments and their geographical concentration in regions close to one another. Our objective has been to use retrotyping, microsatellites and single nucleotide polymorphisms to explore the origins of the breeds and whether, despite their similar adaptations and proximity, they are genetically distinctive. We find the three breeds each have a surprisingly different pattern of retrovirus insertions into their genomes compared with one another and with other UK breeds. Uniquely, there is a high incidence of the R0 retrotype in the Herdwick population, characteristic of a primitive genome found previously in very few breeds worldwide and none in the UK mainland. The Herdwick and Rough Fells carry two rare retroviral insertion events, common only in Texels, suggesting sheep populations in the northern uplands have a historical association with the original pin-tail sheep of Texel Island. Microsatellite data and analyses of SNPs associated with RXFP2 (horn traits) and PRLR (reproductive performance traits) also distinguished the three breeds. Significantly, an SNP linked to TMEM154, a locus controlling susceptibility to infection by Maedi-Visna, indicated that all three native hill breeds have a lower than average risk of infection to the lentivirus.

How young people cope with chronic kidney disease: literature review

BACKGROUND

Chronic kidney disease (CKD) is a complex, long-term condition occurring in all age groups. It has been reported that the incidence of renal replacement therapy in young people is 7-8 per million population. Notwithstanding those individuals who may receive a donor kidney, many individuals may be disenfranchised by perceptions of helplessness and feelings of powerlessness against a backdrop of diminished health outlook, consequently impacting on capacity for effective coping.

AIM

The aim of this review is to explore how young people cope with CKD.

METHODS

Three hundred and thirty-seven abstracts were identified. Sixty-three papers were cross-examined using a Critical Appraisal Skills Checklist Tool.

RESULTS

Young people face various demands; these may be episodic or ongoing, depending on health and circumstance. The themes this review uncovers are: 'Lack of a Coping Definition'; 'Coping Strategies in Young People'; and 'Barriers to the Understanding of Coping in Young People'.

CONCLUSION

More qualitative research is vital to retrieve 'real-life' perceptions from young people coping with kidney disease to identify how care should be made more explicit for them.

Prevention and management of chronic disease in Aboriginal and Islander Community Controlled Health Services in Queensland: a quality improvement study assessing change in selected clinical performance indicators over time in a cohort of services

OBJECTIVE

To evaluate clinical healthcare performance in Aboriginal Medical Services in Queensland and to consider future directions in supporting improvement through measurement, target setting and standards development.

DESIGN

Longitudinal study assessing baseline performance and improvements in service delivery, clinical care and selected outcomes against key performance indicators 2009-2010.

SETTING

27 Aboriginal and Islander Community Controlled Health Services (AICCHSs) in Queensland, who are members of the Queensland Aboriginal and Islander Health Council (QAIHC).

PARTICIPANTS

22 AICCHS with medical clinics.

INTERVENTION

Implementation and use of an electronic clinical information system that integrates with electronic health records supported by the QAIHC quality improvement programme-the Close the Gap Collaborative.

MAIN OUTCOME MEASURES

Proportion of patients with current recording of key healthcare activities and the prevalence of risk factors and chronic disease.

RESULTS

Aggregated performance was high on a number of key risk factors and healthcare activities including assessment of tobacco use and management of hypertension but low for others. Performance between services showed greatest variation for care planning and health check activity.

CONCLUSIONS

Data collected by the QAIHC health information system highlight the risk factor workload facing the AICCHS in Queensland, demonstrating the need for ongoing support and workforce planning. Development of targets and weighting models is necessary to enable robust between-service comparisons of performance, which has implications for health reform initiatives in Australia. The limited information available suggests that although performance on key activities in the AICCHS sector has potential for improvement in some areas, it is nonetheless at a higher level than for mainstream providers.

IMPLICATIONS

The work demonstrates the role that the Community Controlled sector can play in closing the gap in Aboriginal and Torres Strait Islander health outcomes by leading the use of clinical data to record and assess the quality of services and health outcome.

Personality disorders in hypochondriasis: prevalence and comparison with two anxiety disorders

OBJECTIVE

Symptoms of hypochondriasis are sometimes attributed to personality psychopathology by health care providers. The goals of this study were to assess the prevalence of personality disorder (PD) comorbidity in hypochondriasis (HYP) and to compare the PD comorbidity profile of patients with HYP with that found among patients with other disorders characterized by intrusive thoughts and fears.

METHODS

Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders (SCID-I and SCID-II) were administered to 179 individuals: 62 with HYP, 46 with obsessive-compulsive disorder (OCD), and 71 with social anxiety disorder (SAD). For group contrasts, the samples were "purified" of the comparison comorbid disorders. General linear models were used to test the combined effect of group (HYP, OCD, SAD), age, and gender on the PD outcome variables.

RESULTS

59.7% of HYP subjects had no Axis II comorbidity. The most common PDs in HYP were paranoid (19.4%), avoidant (17.7%), and obsessive-compulsive (14.5%). HYP significantly differed from SAD in the likelihood of a cluster C disorder, whereas no significant difference was noted for HYP vs. OCD. The proportion of subjects having at least two PDs was not significantly different for HYP vs. OCD or for HYP vs. SAD.

CONCLUSION

Although 40% of patients with hypochondriasis have PD comorbidity as assessed by the SCID-II, the amount of PD comorbidity is not significantly different than found among individuals with two comparison anxiety disorders. Therefore, health providers should be aware that PD may complicate the clinical profile of HYP, but they should avoid assuming that PD psychopathology is the primary source of hypochondriacal distress.

Understanding and assessing the impact of end-stage renal disease on quality of life: a systematic review of the content validity of self-administered instruments used to assess health-related quality of life in end-stage renal disease

Advances in healthcare, combined with an increasing number of adults with end-stage renal disease (ESRD), mean that there is a growing number of people now surviving on renal replacement therapy. The issue of health-related quality of life (HR-QOL) is becoming increasingly important in this area. For this reason, the content validity of various instruments used to measure HR-QOL in an ESRD population were explored. Systematic searches of MEDLINE (1950-2009) were conducted using terms related to ESRD combined with terms associated with measuring HR-QOL. A total of 378 abstracts were identified, detailing the repeated use of six generic measures and four disease-specific measures. The generic HR-QOL measures discussed include the Medical Outcomes 36-Item Short Form Survey (SF-36), the EuroQOL 5 Dimension (EQ-5D), and the WHO QOL assessment (WHOQOL-BREF). The most frequently used disease-specific measure discussed is the Kidney Disease QOL instrument (KDQOL) and its derivative versions (KDQOL-SF, KDQOL-36). The appropriateness of using the SF-36 in this population is challenged and recommendations include using the WHOQOL-BREF in cases when a generic instrument is required and the KDQOL-SF when a more disease-specific measurement is called for.

Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial

OBJECTIVES

Functional (psychogenic or somatoform) symptoms are common in neurology clinics. Cognitive-behavioral therapy (CBT) can be an effective treatment, but there are major obstacles to its provision in practice. We tested the hypothesis that adding CBT-based guided self-help (GSH) to the usual care (UC) received by patients improves outcomes.

METHODS

We conducted a randomized trial in 2 neurology services in the United Kingdom. Outpatients with functional symptoms (rated by the neurologist as "not at all" or only "somewhat" explained by organic disease) were randomly allocated to UC or UC plus GSH. GSH comprised a self-help manual and 4 half-hour guidance sessions. The primary outcome was self-rated health on a 5-point clinical global improvement scale (CGI) at 3 months. Secondary outcomes were measured at 3 and 6 months.

RESULTS

In this trial, 127 participants were enrolled, and primary outcome data were collected for 125. Participants allocated to GSH reported greater improvement on the primary outcome (adjusted common odds ratio on the CGI 2.36 [95% confidence interval 1.17-4.74; p = 0.016]). The absolute difference in proportion "better" or "much better" was 13% (number needed to treat was 8). At 6 months the treatment effect was no longer statistically significant on the CGI but was apparent in symptom improvement and in physical functioning.

CONCLUSIONS

CBT-based GSH is feasible to implement and efficacious. Further evaluation is indicated.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that CBT-based GSH therapy improves self-reported general health, as measured by the CGI, in patients with functional neurologic symptoms.

Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'

OBJECTIVES

To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease.

METHODS

As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status.

RESULTS

3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)).

CONCLUSIONS

New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

BACKGROUND

Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.

METHOD

The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later.

RESULTS

The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome.

CONCLUSIONS

Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.