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Nisticò V, Goeta D, Gambini O, Demartini B. The psychological impact of COVID-19 among a sample of Italian patients with functional neurological disorders: A preliminary study. Parkinsonism Relat Disord 2020; 78:79-81. [PMID: 32745981 PMCID: PMC7374122 DOI: 10.1016/j.parkreldis.2020.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Veronica Nisticò
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy; "Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università degli Studi di Milano, Milano, Italy
| | - Diana Goeta
- Unità di Psichiatria II, A.O. San Paolo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Orsola Gambini
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy; "Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università degli Studi di Milano, Milano, Italy; Unità di Psichiatria II, A.O. San Paolo, ASST Santi Paolo e Carlo, Milano, Italy
| | - Benedetta Demartini
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy; "Aldo Ravelli" Research Center for Neurotechnology and Experimental Brain Therapeutics, Università degli Studi di Milano, Milano, Italy; Unità di Psichiatria II, A.O. San Paolo, ASST Santi Paolo e Carlo, Milano, Italy.
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Ganslev CA, Storebø OJ, Callesen HE, Ruddy R, Søgaard U. Psychosocial interventions for conversion and dissociative disorders in adults. Cochrane Database Syst Rev 2020; 7:CD005331. [PMID: 32681745 PMCID: PMC7388313 DOI: 10.1002/14651858.cd005331.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them. OBJECTIVES To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults. SEARCH METHODS We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial). DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias. MAIN RESULTS We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1). The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17 studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect. AUTHORS' CONCLUSIONS The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.
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Affiliation(s)
- Christina A Ganslev
- Clinic of Liaison Psychiatry, Region Zealand, Denmark
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | | | - Ulf Søgaard
- Clinic of Liaison Psychiatry, Region Zealand, Denmark
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
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Lidstone SC, Araújo R, Stone J, Bloem BR. Ten myths about functional neurological disorder. Eur J Neurol 2020; 27:e62-e64. [DOI: 10.1111/ene.14310] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023]
Affiliation(s)
- S. C. Lidstone
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease Faculty of Medicine Toronto Western Hospital University of Toronto Toronto ON Canada
| | - R. Araújo
- Department of Neurology Centro Hospitalar Universitário de São João Porto Portugal
- Department of Clinical Neurosciences and Mental Health Faculty of Medicine of University of Porto Porto Portugal
| | - J. Stone
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK
| | - B. R. Bloem
- Donders Institute for Brain Cognition and Behaviour Department of Neurology Centre of Expertise for Parkinson & Movement Disorders Radboud University Medical Centre Nijmegen The Netherlands
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Rather MA, Cavanna AE. Nonepileptic attack disorder and functional movement disorder: A clinical continuum? Epilepsy Behav 2020; 106:107028. [PMID: 32203928 DOI: 10.1016/j.yebeh.2020.107028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
Nonepileptic attack disorder (NEAD) and functional movement disorder (FMD) are functional neurological disorders commonly seen in neuropsychiatry services. Although their initial referral pathways involve epileptologists (NEAD) and specialists in movement disorders (FMD), these conditions are currently classified as two possible manifestations of a single underlying conversion disorder. We set out to compare the characteristics of patients with NEAD and patients with FMD in order to quantify the degree of overlap between these patient groups. We retrospectively reviewed comprehensive clinical data from 146 consecutive patients with functional neurological disorders (NEAD: n = 117; FMD: n = 29) attending a specialist Neuropsychiatry Clinic run by a single Consultant in Behavioral Neurology. The two clinical groups were directly compared with regard to demographic and clinical characteristics, as well as somatic and psychiatric presentations. The results showed that in most features, there were no significant differences between patients with NEAD and patients with FMD. However, patients with NEAD reported an earlier age at onset (p = 0.033) and a higher proportion of acute onset (p = 0.037), alterations of consciousness (p = 0.001), and headache (p = 0.042), whereas patients with FMD reported a higher prevalence of childhood abuse (p = 0.008), as well as mobility problems (p = 0.007) and comorbid functional symptoms (dysarthria, p = 0.004; dizziness, p = 0.035; weakness, p = 0.049). Despite different phenotypic presentations, NEAD and FMD might represent a clinical continuum, with relevant implications in terms of both diagnostic strategies and treatment approaches.
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Affiliation(s)
- Mohammad Amir Rather
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK
| | - Andrea E Cavanna
- Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK; School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and UCL, London, UK.
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Gray C, Calderbank A, Adewusi J, Hughes R, Reuber M. Symptoms of posttraumatic stress disorder in patients with functional neurological symptom disorder. J Psychosom Res 2020; 129:109907. [PMID: 31901839 DOI: 10.1016/j.jpsychores.2019.109907] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To describe prevalence and relevance of Post-Traumatic Stress Disorder (PTSD) symptoms in Functional Neurological Symptom Disorder (FNSD) and explore differences in PTSD symptom scores between subgroups with Psychogenic Non-Epileptic Seizures (PNES) or other FNSD. METHODS This cross-sectional study evaluated data from 430 consecutive patients referred to a specialist psychotherapy service (69.3% female, 56% with PNES/44% with other FNSD). We analysed self-reported symptoms of Post-Traumatic Stress Disorder (PTSD Civilian Checklist, PCLC), depression (PHQ-9), anxiety (GAD-7), physical symptoms (PHQ-15), social functioning (WSAS), and health related quality of life (SF-36). Relationships between PTSD scores, diagnosis and other measures were examined. Independent associations of PTSD scores were identified using multilinear regression. RESULTS Symptom scores likely to indicate clinical PTSD were reported by 60.7% of patients with no difference between PNES and FNSD subgroups. Those potentially symptomatic of PTSD were less likely to be living with a partner OR 2.95 (95% CI 1.83-4.04), or to be in employment OR 2.23 (95% CI 1.46-3.41) than less symptomatic patients. There were higher levels of anxiety (r = 0.62), depression (r = 0.63) and somatic symptoms (r = 0.45) and lower quality of life scores (r = 0.48) in patients with high PTSD symptom scores (p < .0001 for all comparisons). Anxiety, depression and somatic symptoms made independent contributions to the variance of PTSD symptoms. CONCLUSION There is a high prevalence of PTSD symptoms in patient with FNSD regardless of whether they have PNES. Trauma and PTSD symptoms are negatively correlated with quality of life. Self-report instruments for anxiety, depression and somatic symptoms may predict the presence of PTSD.
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Affiliation(s)
- Cordelia Gray
- Neurology Psychotherapy Service, Sheffield Teaching Hospital, Sheffield, UK; Academic Neurology Unit, University of Sheffield, Sheffield, UK.
| | - Alex Calderbank
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
| | - Joy Adewusi
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
| | - Rhiannon Hughes
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
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O'Connell N, Nicholson TR, Wessely S, David AS. Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study. Psychol Med 2020; 50:446-455. [PMID: 30773149 DOI: 10.1017/s0033291719000266] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Functional neurological disorder (FND), previously known as conversion disorder, is common and often results in substantial distress and disability. Previous research lacks large sample sizes and clinical surveys are most commonly derived from neurological settings, limiting our understanding of the disorder and its associations in other contexts. We sought to address this by analysing a large anonymised electronic psychiatric health record dataset. METHODS Data were obtained from 322 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who had an ICD-10 diagnosis of motor FND (mFND) (limb weakness or disorders of movement or gait) between 1 January 2006 and 31 December 2016. Data were collected on a range of socio-demographic and clinical factors and compared to 644 psychiatric control patients from the same register. RESULTS Weakness was the most commonly occurring functional symptom. mFND patients were more likely to be female, British, married, employed pre-morbidly, to have a carer and a physical health condition, but less likely to have had an inpatient psychiatric admission or to receive benefits. No differences in self-reported sexual or physical abuse rates were observed between groups, although mFND patients were more likely to experience life events linked to inter-personal difficulties. CONCLUSIONS mFND patients have distinct demographic characteristics compared with psychiatric controls. Experiences of abuse appear to be equally prevalent across psychiatric patient groups. This study establishes the socio-demographic and life experience profile of this understudied patient group and may be used to guide future therapeutic interventions designed specifically for mFND.
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Affiliation(s)
- N O'Connell
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T R Nicholson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - S Wessely
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - A S David
- UCL Institute of Mental Health Studies, University College London, London, UK
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Abstract
PURPOSE OF REVIEW This article reviews a practical approach to psychogenic movement disorders to help neurologists identify and manage this complex group of disorders. RECENT FINDINGS Psychogenic movement disorders, also referred to as functional movement disorders, describe a group of disorders that includes tremor, dystonia, myoclonus, parkinsonism, speech and gait disturbances, and other movement disorders that are incongruent with patterns of pathophysiologic (organic) disease. The diagnosis is based on positive clinical features that include variability, inconsistency, suggestibility, distractibility, suppressibility, and other supporting information. While psychogenic movement disorders are often associated with psychological and physical stressors, the underlying pathophysiology is not fully understood. Although insight-oriented behavioral and pharmacologic therapies are helpful, a multidisciplinary approach led by a neurologist, but also including psychiatrists and physical, occupational, and speech therapists, is needed for optimal outcomes. SUMMARY The diagnosis of psychogenic movement disorders is based on clinical features identified on neurologic examination, and neurophysiologic and imaging studies can provide supporting information.
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Kletenik I, Sillau SH, Isfahani SA, LaFaver K, Hallett M, Berman BD. Gender as a Risk Factor for Functional Movement Disorders: The Role of Sexual Abuse. Mov Disord Clin Pract 2019; 7:177-181. [PMID: 32071936 DOI: 10.1002/mdc3.12863] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/27/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022] Open
Abstract
Background The prevalence of functional movement disorders is 2 to 3 times higher in women than in men. Trauma and adverse life events are important risk factors for developing functional movement disorders. On a population level, rates of sexual abuse against women are higher when compared with the rates against men. Objectives To determine gender differences in rates of sexual abuse in functional movement disorders compared with other neurologic disorders and evaluate if the gender prevalence is influenced by higher rates of sexual abuse against women. Methods We performed a case-control series including 199 patients with functional movement disorders (149 women) and 95 controls (60 women). We employed chi-squared test to assess gender and sexual abuse associations and Bayes formula to condition on sexual abuse. Results Our analysis showed an association between sexual abuse and functional movement disorders in women (odds ratio, 4.821; 95% confidence interval, 2.089-12.070; P < 0.0001), but not men. Bayesian analysis found the functional movement disorder prevalence ratio between women and men conditional on sexual abuse to be 4.87 times the unconditioned ratio. Conclusions There is a statistically significant association between sexual abuse and functional movement disorders in women and a greater likelihood that women who are sexually abused will develop functional movement disorders than men who are sexually abused. Our findings suggest that the increased prevalence of functional movement disorders in women is associated, at least in part, with sexual abuse and its sequelae; however, further research is needed to explore the role of other traumatic and nontraumatic factors.
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Affiliation(s)
- Isaiah Kletenik
- Department of Neurology University of Colorado School of Medicine Aurora Colorado USA.,Behavioral Neurology Section University of Colorado School of Medicine Aurora Colorado USA
| | - Stefan H Sillau
- Department of Neurology University of Colorado School of Medicine Aurora Colorado USA
| | - Sanaz Attaripour Isfahani
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland USA
| | - Kathrin LaFaver
- Department of Neurology, Movement Disorder Division University of Louisville Louisville Kentucky USA.,Department of Neurology Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland USA
| | - Brian D Berman
- Department of Neurology University of Colorado School of Medicine Aurora Colorado USA.,Movement Disorders Center University of Colorado School of Medicine Aurora Colorado USA
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Personality and Psychopathology in Patients With Mixed Sensory-Motor Functional Neurological Disorder (Conversion Disorder): A Pilot Study. J Nerv Ment Dis 2019; 207:546-554. [PMID: 31206424 DOI: 10.1097/nmd.0000000000001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this pilot study was to explore differences in the level of personality functioning, symptom severity, and personality pathology in patients with mixed sensory-motor functional neurological disorder (conversion disorder). Individuals with psychogenic nonepileptic seizures were not included. We recruited 15 patients, mean age of 33.5 years (SD, 11.4 years), 13 females and 2 males, from an outpatient clinic for psychotherapeutic treatment. We assessed the patients using the Structured Clinical Interview for DSM-4 Axis II Personality Disorders, the SCL-90-R, the Karolinska Psychodynamic Profile, and the Defense Style Questionnaire. We were able to distinguish two levels of difficulty in relation to personality functioning as distinct subgroups: 1) "neurotic" with less severe or moderate personality psychopathology and 2) "borderline" with severe personality psychopathology. Furthermore, we concluded that all patients showed severe deficits in personality functioning. The study points out the clinical relevance of identifying personality functioning as part of an assessment in the preparation of a treatment strategy.
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Affiliation(s)
- Richard A A Kanaan
- Department of Psychiatry, Austin Health,University of Melbourne,Heidelberg, VIC 3084,Australia
| | - Thomas K J Craig
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College,London,UK
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Versace V, Campostrini S, Sebastianelli L, Soda M, Saltuari L, Lun S, Nardone R, Kofler M. Adult-Onset Gilles de la Tourette Syndrome: Psychogenic or Organic? The Challenge of Abnormal Neurophysiological Findings. Front Neurol 2019; 10:461. [PMID: 31130912 PMCID: PMC6509948 DOI: 10.3389/fneur.2019.00461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/16/2019] [Indexed: 11/13/2022] Open
Abstract
Gilles de la Tourette syndrome (GTS) is characterized by multiple motor and vocal tics. Adult-onset cases are rare and may be due to "reactivation" of childhood tics, or secondary to psychiatric or genetic diseases, or due to central nervous system lesions of different etiologies. Late-onset psychogenic motor/vocal tics resembling GTS have been described. Neurophysiology may serve to differentiate organic from functional GTS. Altered blink reflex pre-pulse inhibition (BR-PPI), blink reflex excitability recovery (BR-ERC), and short-interval intracortical inhibition (SICI) have been described in GTS. We report a 48-years-old male, who developed numerous motor/vocal tics 2 months after sustaining non-commotional craniofacial trauma in a car accident. Both his father and brother had died earlier in car crashes. He presented with blepharospasm-like forced lid closure, forceful lip pursing, noisy suction movements, and deep moaning sounds, occurring in variable combinations, without warning symptoms or internal "urge." Tics showed low distractibility and these increased with attention. Standard magnetic resonance imaging, electroencephalography, and evoked potentials were unremarkable. Neuropsychology diagnosed moderately impaired intellect, attention, and executive functions. Psychiatric assessment revealed somatization disorder and generalized anxiety. BR-PPI was unremarkable, while BR-ERC was enhanced, even showing facilitation at short intervals. SICI was markedly reduced at 1 and 3 ms and intracortical facilitation (ICF) was enhanced at 10 ms. The patient fulfilled Fahn and Williams' diagnostic criteria for a psychogenic movement disorder. Neurophysiology, however, documented hyperexcitability of motor cortex and brainstem. We suggest that-similar to what has been reported in psychogenic dystonia-a pre-existing predisposition may have led to the functional hyperkinetic disorder in response to severe psychic stress.
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Affiliation(s)
- Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Stefania Campostrini
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Luca Sebastianelli
- Department of Neurorehabilitation, Hospital of Vipiteno, Vipiteno, Italy.,Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy
| | - Mirco Soda
- Department of Neuropsychology, Hospital of Bressanone, Bressanone, Italy
| | - Leopold Saltuari
- Research Unit for Neurorehabilitation South Tyrol, Bolzano, Italy.,Department of Neurology, State Hospital Hochzirl, Zirl, Austria
| | - Sigrid Lun
- Department of Psychiatry, Hospital of Bressanone, Bressanone, Italy
| | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy.,Department of Neurology, Christian Doppler Medical Center, Paracelsus Private Medical University of Salzburg, Salzburg, Austria
| | - Markus Kofler
- Department of Neurology, State Hospital Hochzirl, Zirl, Austria
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Barnett C, Armes J, Smith C. Speech, language and swallowing impairments in functional neurological disorder: a scoping review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:309-320. [PMID: 30592118 DOI: 10.1111/1460-6984.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/27/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is common across healthcare settings. The Diagnostic and Statistical Manual of Mental Disorders states that speech and swallowing symptoms can be present in FND. Despite this, there is a dearth of guidelines for speech and language therapists (SLTs) for this client group. AIMS To address the following question in order to identify gaps for further research: What is known about speech, language and swallowing symptoms in patients with FND? METHODS & PROCEDURES A scoping review was conducted. Six healthcare databases were searched for relevant literature: CINAHL PLUS, MEDLINE, ProQuest Nursing and Allied Health Professionals, Science Citation Index, Scopus, and PsychINFO. The following symptoms were excluded from the review: dysphonia, globus pharyngeus, dysfluency, foreign accent syndrome and oesophageal dysphagia. MAIN CONTRIBUTION A total of 63 papers were included in the final review; they ranged in date from 1953 to 2018. Case studies were the most frequent research method (n = 23, 37%). 'Psychogenic' was the term used most frequently (n = 24, 38%), followed by 'functional' (n = 21, 33%). Speech symptoms were reported most frequently (n = 41, 65%), followed by language impairments (n = 35, 56%) and dysphagia (n = 13, 21%). Only 11 publications comment on the involvement of SLTs. Eight papers report direct speech and language therapy input; however, none studied the effectiveness of speech and language therapy. CONCLUSIONS & IMPLICATIONS Speech, language and swallowing symptoms do occur in patients with FND, yet it is a highly under-researched area. Further research is required to create a set of positive diagnostic criteria, gather accurate data on numbers of patients with FND and speech, language or swallowing symptoms, and to evaluate the effectiveness of direct speech and language therapy involvement.
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Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean Armes
- Birmingham Community Healthcare NHS Trust, Birmingham, UK
| | - Christina Smith
- Department of Language and Cognition, University College London, London, UK
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O'Connell N, Nicholson T, Blackman G, Tavener J, David AS. Medication prescriptions in 322 motor functional neurological disorder patients in a large UK mental health service: A case control study. Gen Hosp Psychiatry 2019; 58:94-102. [PMID: 31031213 DOI: 10.1016/j.genhosppsych.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This study describes medication prescribing patterns in patients with motor functional neurological disorder (mFND) treated in South London and Maudsley NHS Foundation Trust (SLaM), comparing outcomes to a control group of psychiatric patients from the same hospital trust. METHOD This is a retrospective case-control study using a psychiatric case register. Cross-sectional data were obtained from 322 mFND patients and 644 psychiatry controls who had had contact with SLaM between 1st January 2006 and 31st December 2016. RESULTS A slightly lower proportion of mFND patients received medication compared to controls (76.6% v. 83.4%, OR: 0.59, CI: 0.39-0.89, p < 0.05). Of medication recipients, mFND patients were prescribed a higher number of agents (mean: 4.7 v 2.9, p = 0.001) and had higher prescription rates of antidepressants, anti-epileptics, analgesics, and certain non-psychotropic medications. Higher numbers of prescriptions were associated with co-morbid physical conditions, and previous psychiatric admissions. CONCLUSIONS This is the first study to describe medication prescriptions in a large cohort of mFND patients. Patients were prescribed a wide range of psychiatric and physical health medications, with higher rates of polypharmacy than controls. Psychotropic medication prescription is not necessarily the first line treatment for mFND, where physiotherapy and psychotherapy may be offered initially. There is limited, early-phase evidence for pharmacological therapies for mFND, and as such, the benefit-to-risk ratio of prescribing in this complex and poorly understood disorder should be carefully assessed.
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Affiliation(s)
- Nicola O'Connell
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom. nicola.k.o'
| | - Timothy Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Graham Blackman
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Jennifer Tavener
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Anthony S David
- Institute of Mental Health, UCL Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom.
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Zito GA, Apazoglou K, Paraschiv-Ionescu A, Aminian K, Aybek S. Abnormal postural behavior in patients with functional movement disorders during exposure to stress. Psychoneuroendocrinology 2019; 101:232-239. [PMID: 30471572 DOI: 10.1016/j.psyneuen.2018.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients affected by functional (psychogenic) movement disorders (FMD) have abnormal processing of stress responses. However, little is known about the influence of this abnormal stress processing on automatic motor defense behavior, such as freeze response. Our aim was thus to investigate stress-induced postural motor responses in FMD. METHODS Nine FMD patients and thirteen healthy controls were engaged in the Trier Social Stress Test, while we measured the movement of their body by means of accelerometers and gyroscopes attached to the thorax. Standard deviation of thorax acceleration, reflecting the variability of movement amplitude (body sway), was compared across groups over time in a 2 × 2 ANOVA design. Higuchi's fractal dimension (HFD), reflecting the complexity of movement pattern over time, was also analyzed. Salivary cortisol and α-amylase samples were collected before and after the experiment, as stress biomarkers. Pearson's correlation coefficients were calculated between these biomarkers and movement parameters. RESULTS A significant interaction effect was found, showing that healthy controls reduced their thorax sway over time during exposure to stress (from 0.027 ± 0.010 m/s2 to 0.023 ± 0.008 m/s2, effect size of Cohen's d = 0.95), whereas patients with FMD did not. This change in body sway in controls over time negatively correlated with salivary cortisol values (ρ = -0.67, p = 0.012). A significant group effect revealed that FMD patients had an overall larger body sway (0.038 ± 0.013 m/s2) compared to controls (0.025 ± 0.009 m/s2 - effect size of Cohen's d = 1.29) and a lower HFD (1.602 ± 0.071) than controls (1.710 ± 0.078 - Cohen's d = 1.43). CONCLUSIONS Patients with FMD failed to show a reduction of body sway over time, i.e., freeze response observed in the controls, thus suggesting an impairment in the automatic defense behavior. Moreover, our analysis found a lower complexity of movement (HFD) in FMD, which deserves future research in order to verify whether this could represent a characteristic trait of the disorder.
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Affiliation(s)
- Giuseppe Angelo Zito
- Department of Neurology, Inselspital, Bern University Hospital, Freiburgstrasse, CH-3010 Bern, Switzerland; Support Centre for Advanced Neuroimaging (SCAN), University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Kallia Apazoglou
- Department of Neuroscience, Faculty of Medicine, University of Geneva, 24 rue du Général-Dufour, 1211 Geneva, Switzerland.
| | - Anisoara Paraschiv-Ionescu
- Laboratory of Movement Analysis and Measurement, École Polytechnique Fédérale de Lausanne (EPFL), Route Cantonale, 1015 Lausanne, Switzerland.
| | - Kamiar Aminian
- Laboratory of Movement Analysis and Measurement, École Polytechnique Fédérale de Lausanne (EPFL), Route Cantonale, 1015 Lausanne, Switzerland.
| | - Selma Aybek
- Department of Neurology, Inselspital, Bern University Hospital, Freiburgstrasse, CH-3010 Bern, Switzerland; Department of Neuroscience, Faculty of Medicine, University of Geneva, 24 rue du Général-Dufour, 1211 Geneva, Switzerland.
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Baizabal-Carvallo JF, Hallett M, Jankovic J. Pathogenesis and pathophysiology of functional (psychogenic) movement disorders. Neurobiol Dis 2019; 127:32-44. [PMID: 30798005 DOI: 10.1016/j.nbd.2019.02.013] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 11/17/2022] Open
Abstract
Functional movement disorders (FMDs), known over time as "hysteria", "dissociative", "conversion", "somatoform", "non-organic" and "psychogenic" disorders, are characterized by having a voluntary quality, being modifiable by attention and distraction but perceived by the patient as involuntary. Although a high prevalence of depression and anxiety is observed in these patients, a definitive role of psychiatric disorders in FMDs has not been proven, and many patients do not endorse such manifestations. Stressful events, social influences and minor trauma may precede the onset of FMDs, but their pathogenic mechanisms are unclear. Patients with FMDs have several abnormalities in their neurobiology including strengthened connectivity between the limbic and motor networks. Additionally, there is altered top-down regulation of motor activities and increased activation of areas implicated in self-awareness, self-monitoring, and active motor inhibition such as the cingulate and insular cortex. Decreased activation of the supplementary motor area (SMA) and pre-SMA, implicated in motor control and preparation, is another finding. The sense of agency defined as the feeling of controlling external events through one's own action also seems to be impaired in individuals with FMDs. Correlating with this is a loss of intentional binding, a subjective time compression between intentional action and its sensory consequences. Organic and functional dystonia may be difficult to differentiate since they share diverse neurophysiological features including decreased cortical inhibition, and similar local field potentials in the globus pallidus and thalamus; although increased cortical plasticity is observed only in patients with organic dystonia. Advances in the pathogenesis and pathophysiology of FMDs may be helpful to understand the nature of these disorders and plan further treatment strategies.
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Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; University of Guanajuato, Mexico.
| | - Mark Hallett
- Human Motor Control Section, NINDS, National Institutes of Health, Bethesda, MD, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Fobian AD, Elliott L. A review of functional neurological symptom disorder etiology and the integrated etiological summary model. J Psychiatry Neurosci 2019; 44:8-18. [PMID: 30565902 PMCID: PMC6306282 DOI: 10.1503/jpn.170190] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Functional neurological symptom disorder (FNSD) is characterized by neurological symptoms that are unexplained by other traditional neurological or medical conditions. Both physicians and patients have limited understanding of FNSD, which is often explained as a physical manifestation of psychological distress. Recently, diagnostic criteria have shifted from requiring a preceding stressor to relying on positive symptoms. Given this shift, we have provided a review of the etiology of FNSD. Predisposing factors include trauma or psychiatric symptoms, somatic symptoms, illness exposure, symptom monitoring and neurobiological factors. Neurobiological research has indicated that patients with FNSD have a decreased sense of agency and abnormal attentional focus on the affected area, both of which are modulated by beliefs and expectations about illness. Sick role and secondary gain may reinforce and maintain FNSD. The integrated etiological summary model combines research from various fields and other recent etiological models to represent the current understanding of FNSD etiology. It discusses a potential causal mechanism and informs future research and treatment.
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Affiliation(s)
- Aaron D. Fobian
- From the Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL (Fobian); and the Department of Psychology, University of Alabama at Birmingham, Birmingham, AL (Elliott)
| | - Lindsey Elliott
- From the Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL (Fobian); and the Department of Psychology, University of Alabama at Birmingham, Birmingham, AL (Elliott)
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Gendre T, Carle G, Mesrati F, Hubsch C, Mauras T, Roze E, Houot M, Degos B, Garcin B. Quality of life in functional movement disorders is as altered as in organic movement disorders. J Psychosom Res 2019; 116:10-16. [PMID: 30654984 DOI: 10.1016/j.jpsychores.2018.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/15/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Patients with functional movement disorders (FMD) often report a disability and psychiatric comorbidities. However, few studies have compared these aspects in FMD and in organic movement disorders (OMD). The objectives were to compare QoL and psychiatric comorbidities of FMD and OMD patients. METHODS Twenty-one and 30 FMD patients were compared to 21 and 30 sex- and age-matched dystonia and Parkinson patients respectively. QoL was assessed using the Parkinson's Disease Summary Index (PDSI). Psychiatric comorbidities were screened with the Mini International Neuropsychiatric Interview, the Hospital Anxiety and Depression Scale and the Composite International Diagnostic Interview questionnaire. RESULTS QoL was more altered in FMD than in dystonia on PDSI (42.1 vs 25.1; p = .003). No significant difference was observed in QoL in FMD and Parkinson's disease on PDSI (38.3 vs 32.2; p = .61). Moreover, FMD patients were more often unemployed because of their condition than dystonia (61.9% vs 14.3%; p = .01) and Parkinson patients (53.3% vs 13.3%; p = .005). The occurrence of anxiety (p = .58 and > 0.99), depression (p = .77 and 0.77), and traumatic events (p = .58 and 0.75) was not different between groups. FMD patients reported more often sexual abuse than dystonia (28,6% vs 4.8%; p = .13) and Parkinson patients (23.3% vs 0.0%; p = .02). CONCLUSION FMD patients presented a significant alteration of QoL and no increased psychiatric comorbidities compared to OMD patients. These results highlight the impact of FMD and suggest that neurologists should be as involved in the management of FMD as they are in OMD.
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Affiliation(s)
- Thierry Gendre
- Department of Neurology, Henri Mondor University Hospital, AP-HP, Créteil, France; Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France.
| | - Guilhem Carle
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France; Brain and Spine Institute, UPMC UMRS 1127, INSERM U1127, CNRS UMR 7225, Paris, France
| | - Francine Mesrati
- Department of Neurophysiology, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Cécile Hubsch
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Thomas Mauras
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Emmanuel Roze
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France; Brain and Spine Institute, UPMC UMRS 1127, INSERM U1127, CNRS UMR 7225, Paris, France
| | - Marion Houot
- Sorbonne University, GRC n°21, Alzheimer Precision Medicine (APM), Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Bertrand Degos
- Centre for Interdisciplinary Research in Biology, Collège de France, INSERM U1050, CNRS UMR7241, Labex Memolife, Paris Sciences et Lettres, Paris, France; Department of Neurology, Avicenne University Hospital, Paris - Seine Saint-Denis University Hospitals, Bobigny, France
| | - Béatrice Garcin
- Brain and Spine Institute, UPMC UMRS 1127, INSERM U1127, CNRS UMR 7225, Paris, France; Department of Neurology, Avicenne University Hospital, Paris - Seine Saint-Denis University Hospitals, Bobigny, France
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Kaas BM, Humbyrd CJ, Pantelyat A. Functional Movement Disorders and Placebo: A Brief Review of the Placebo Effect in Movement Disorders and Ethical Considerations for Placebo Therapy. Mov Disord Clin Pract 2018; 5:471-478. [PMID: 30515436 DOI: 10.1002/mdc3.12641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 12/17/2022] Open
Abstract
Background Functional movement disorders are common and disabling neurologic conditions. Patients with functional neurologic disorders represent a large proportion of neurology clinic referrals, and limited availability of subspecialty care creates a considerable burden for the healthcare system. These conditions are currently treated with a combination of physical therapy and cognitive behavioral therapy, with variable success. Methods We searched the Medline database for studies on the epidemiology and physiology of functional movement disorders, as well as those on the placebo effect in movement disorders. We reviewed and summarized the literature on these topics and explored ethical issues concerning the administration of placebos to patients with functional movement disorders. Results Studies of placebos, particularly in patients with movement disorders, have shown that these "inert" agents can provide demonstrable neurophysiologic benefits, even in open-label studies. Physician surveys have shown that many administer placebos for diagnostic and therapeutic purposes, although there are ethical concerns about this practice. We used a principle-based approach and reviewed ethical arguments for (justice and beneficence) and against (non-maleficence and autonomy) the use of placebos in functional movement disorders. In this context, we argue for the importance of the therapeutic alliance in preserving patient autonomy while exploring the potential benefits of placebo therapy. Conclusions An ethical argument is presented in support of nondeceptive clinical placebo use for the treatment of functional movement disorders. Patient and clinician attitudes regarding the use of placebos should be investigated before placebo-therapy trials are conducted.
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Affiliation(s)
- Bonnie M Kaas
- Department of Neurology Johns Hopkins University School of Medicine Baltimore MD
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery Johns Hopkins University School of Medicine Baltimore MD.,The Berman Institute of Bioethics Johns Hopkins University School of Medicine Baltimore MD
| | - Alexander Pantelyat
- Department of Neurology Johns Hopkins University School of Medicine Baltimore MD
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Věchetová G, Slovák M, Kemlink D, Hanzlíková Z, Dušek P, Nikolai T, Růžička E, Edwards MJ, Serranová T. The impact of non-motor symptoms on the health-related quality of life in patients with functional movement disorders. J Psychosom Res 2018; 115:32-37. [PMID: 30470314 DOI: 10.1016/j.jpsychores.2018.10.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/27/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Pain, fatigue, cognitive complaints and psychiatric comorbidities are common in patients with functional movement disorder and may significantly affect their quality of life. The aim of the study was to assess the impact of motor and non-motor symptoms on health-related quality of life in patients with functional movement disorder. METHODS Sixty-one patients with clinically established functional movement disorder and 61 matched healthy controls completed standardized questionnaires for depression, anxiety, cognitive complaints, fatigue, pain, sleepiness, apathy and health-related quality of life. Motor disorder severity was assessed using The Simplified Functional Movement Disorders Rating Scale. Personality traits were assessed using the 44-Item Big Five Inventory. RESULTS Compared to controls, patients reported significantly lower health-related quality of life and higher levels of all assessed non-motor symptoms except for apathy. No difference was found in personality traits. In both groups, health-related quality of life scores negatively correlated with depression, anxiety, pain, cognitive complaints, apathy, and neuroticism. No correlation was found between health-related quality of life and motor symptom severity in patients with functional movement disorder. Multiple regression analysis of the predictors of health-related quality of life showed significant impact of trait anxiety and cognitive complaints scores. CONCLUSIONS Multiple non-motor symptoms but not motor symptom severity correlated with impaired health-related quality of life in patients with functional movement disorder. Impaired health-related quality of life was predicted by anxiety and cognitive complaints. Our results highlight the importance of assessing and treating both motor and non-motor symptoms in patients with functional movement disorder.
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Affiliation(s)
- Gabriela Věchetová
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Matěj Slovák
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Kemlink
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Hanzlíková
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Dušek
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomáš Nikolai
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Evžen Růžička
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Mark J Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University of London, United Kingdom
| | - Tereza Serranová
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
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Sojka P, Bareš M, Kašpárek T, Světlák M. Processing of Emotion in Functional Neurological Disorder. Front Psychiatry 2018; 9:479. [PMID: 30344497 PMCID: PMC6182079 DOI: 10.3389/fpsyt.2018.00479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/13/2018] [Indexed: 01/25/2023] Open
Abstract
Emotions have traditionally been considered crucial in the development of functional neurological disorder, but the evidence underpinning this association is not clear. We aimed to summarize evidence for association between functional neurological disorder and emotions as formulated by Breuer and Freud in their conception of hysterical conversion. Based on a systematic literature search, we identified 34 controlled studies and categorized them into four groups: (i) autonomic arousal, (ii) emotion-motion interactions, (iii) social modulation of symptoms, and (iv) bodily awareness in FND. We found evidence for autonomic dysregulation in FND; convergent neuroimaging findings implicate abnormal limbic-motor interactions in response to emotional stimuli in FND. Our results do not provide enough empirical evidence for social modulation of the symptoms, but there is a clinical support for the role of suggestion and placebo in FND. Our results provide evidence for abnormal bodily awareness in FND. Based on these findings, we propose that functional neurological symptoms are forms of emotional reactions shaped into symptoms by previous experience with illness and possibly reinforced by actual social contexts. Additional research should investigate the effect of social context on the intensity of functional neurological symptoms and associated brain regions.
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Affiliation(s)
- Petr Sojka
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
| | - Martin Bareš
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Tomáš Kašpárek
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Miroslav Světlák
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
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Park JE. Clinical Characteristics of Functional Movement Disorders: A Clinic-based Study. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018; 8:504. [PMID: 30191082 PMCID: PMC6123835 DOI: 10.7916/d81n9hk4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 06/18/2018] [Indexed: 12/02/2022]
Abstract
Background Functional movement disorders are recognized as a “crisis” in neurology. We aimed to determine the rate of incidence of functional movement disorder patients at a university outpatient neurology clinic in South Korea, and highlight the clinical and phenomenological characteristics. Methods Patients who were assessed by a movement disorders neurologist at a university hospital between March 2016 and May 2017 were screened for functional movement disorders. Demographic and clinical data were reviewed, and the phenomenology of movements was studied. Results Of 321 patients evaluated for the chief complaint of a movement abnormality, approximately 10% (31 patients) were diagnosed with a functional movement disorder. The female to male ratio was 7:1 (27 females to four males). The mean age at presentation was 53 years (standard error 3.6 years), and the mean disease duration was 5 years (standard error 1.4 years). Sixty-one percent (19 out of 31 patients) had a past medical history of depression, anxiety, or other psychiatric illnesses. Tremor and speech abnormalities were most prevalent (19 and 12 patients, respectively). Onset was reported to be abrupt in 14 patients (45%). Thirteen (42%) patients were found to have improvement at a follow-up visit, 10 (32%) had no improvement, and eight (26%) were lost to follow-up. Discussion Functional movement disorders are not uncommon in the outpatient neurology clinic. Our results confirm that tremor is the most frequent movement occurring in functional movement disorders, and the most commonly affected body parts were found to be the upper and lower extremities. Speech was also found to be frequently involved (39%). Patients with no improvement at follow-up had longer mean disease duration (6.2 years), consistent with previous observations that prolonged symptom duration is associated with poor clinical outcome. Our study results obtained from a Korean population suggest that previous observations on functional movement disorders from other regions hold true in Eastern Asia.
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Affiliation(s)
- Jung E Park
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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Cope SR, Mountford L, Smith JG, Agrawal N. EMDR to Treat Functional Neurological Disorder: A Review. JOURNAL OF EMDR PRACTICE AND RESEARCH 2018. [DOI: 10.1891/1933-3196.12.3.118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Eye movement desensitization and reprocessing (EMDR) therapy is an established treatment for posttraumatic stress disorder (PTSD), but there is increasing evidence for its use beyond PTSD. EMDR can be effective at treating distressing memories not associated with PTSD, as well as somatic symptoms (like chronic pain), and as such could potentially be used as a treatment for patients with functional neurological disorder (FND). Searches were conducted for published peer-reviewed articles on the use of EMDR for FND. The databases selected and searched were Medline, Embase, Cochrane Library, CINAHL Plus, Web of Science, PsychINFO, PubMed, and Francine Shapiro Library. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Three relevant articles were found. The studies included are one case series and two case studies. Of the five participants included in the studies, four experienced functional non-epileptic attacks; and one experienced functional movement disorder. Four out of the five patients were successfully treated with EMDR. EMDR is potentially a useful treatment of FND, but further research, including controlled trials, is required. The authors propose that EMDR could be useful in treating patients with FND and comorbid PTSD, as well as patients without comorbid PTSD. We discuss the clinical implications and propose how EMDR could fit into the FND treatment pathway.
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Fatigue, not self-rated motor symptom severity, affects quality of life in functional motor disorders. J Neurol 2018; 265:1803-1809. [DOI: 10.1007/s00415-018-8915-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/10/2018] [Accepted: 05/20/2018] [Indexed: 02/06/2023]
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Jacob AE, Kaelin DL, Roach AR, Ziegler CH, LaFaver K. Motor Retraining (MoRe) for Functional Movement Disorders: Outcomes From a 1-Week Multidisciplinary Rehabilitation Program. PM R 2018; 10:1164-1172. [PMID: 29783067 DOI: 10.1016/j.pmrj.2018.05.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 05/04/2018] [Accepted: 05/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Functional movement disorders (FMDs) are conditions of abnormal motor control thought to be caused by psychological factors. These disorders are commonly seen in neurologic practice, and prognosis is often poor. No consensus treatment guidelines have been established; however, the role of physical therapy in addition to psychotherapy has increasingly been recognized. This study reports patient outcomes from a multidisciplinary FMD treatment program using motor retraining (MoRe) strategies. OBJECTIVE To assess outcomes of FMD patients undergoing a multidisciplinary treatment program and determine factors predictive of treatment success. DESIGN Retrospective chart review. SETTING University-affiliated rehabilitation institute. PATIENTS Thirty-two consecutive FMD patients admitted to the MoRe program from July 2014-July 2016. INTERVENTION Patients participated in a 1-week, multidisciplinary inpatient treatment program with daily physical, occupational, speech therapy, and psychotherapy interventions. MAIN OUTCOME MEASUREMENTS Primary outcome measures were changes in the patient-rated Clinical Global Impression Scale (CGI) and the physician-rated Psychogenic Movement Disorder Rating Scale (PMDRS) based on review of standardized patient videos. Measurements were taken as part of the clinical evaluation of the program. RESULTS Twenty-four of the 32 patients were female with a mean age of 49.1 (±14.2) years and mean symptom duration of 7.4 (±10.8) years. Most common movement phenomenologies were abnormal gait (31.2%), hyperkinetic movements (31.2%), and dystonia (31.2%). At discharge, 86.7% of patients reported symptom improvement on the CGI, and self-reported improvement was maintained in 69.2% at the 6-month follow-up. PMDRS scores improved by 59.1% from baseline to discharge. Longer duration of symptoms, history of abuse, and comorbid psychiatric disorders were not significant predictors of treatment outcomes. CONCLUSIONS The majority of FMD patients experienced improvement from a 1-week multidisciplinary inpatient rehabilitation program. Treatment outcomes were not negatively correlated with longer disease duration or psychiatric comorbidities. The results from our study are encouraging, although further long-term prospective randomized studies are needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexandra E Jacob
- Department of Neurology, University of Louisville, Louisville, KY(∗)
| | - Darryl L Kaelin
- Division of Physical Medicine and Rehabilitation, University of Louisville, Louisville, KY(†)
| | - Abbey R Roach
- Division of Psychology and Neuropsychology, Frazier Rehab Institute, Louisville, KY(‡)
| | - Craig H Ziegler
- School of Medicine, University of Louisville, Louisville, KY(§)
| | - Kathrin LaFaver
- Department of Neurology, University of Louisville, 220 Abraham Flexner Way, Suite 606, Louisville, KY, 40202(¶).
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Ludwig L, Pasman JA, Nicholson T, Aybek S, David AS, Tuck S, Kanaan RA, Roelofs K, Carson A, Stone J. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. Lancet Psychiatry 2018; 5:307-320. [PMID: 29526521 DOI: 10.1016/s2215-0366(18)30051-8] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Stressful life events and maltreatment have traditionally been considered crucial in the development of conversion (functional neurological) disorder, but the evidence underpinning this association is not clear. We aimed to assess the association between stressors and functional neurological disorder. METHODS We systematically reviewed controlled studies reporting stressors occurring in childhood or adulthood, such as stressful life events and maltreatment (including sexual, physical abuse, and emotional neglect) and functional neurological disorder. We did a meta-analysis, with assessments of methodology, sources of bias, and sensitivity analyses. FINDINGS 34 case-control studies, with 1405 patients, were eligible. Studies were of moderate-to-low quality. The frequency of childhood and adulthood stressors was increased in cases compared with controls. Odds ratios (OR) were higher for emotional neglect in childhood (49% for cases vs 20% for controls; OR 5·6, 95% CI 2·4-13·1) compared with sexual abuse (24% vs 10%; 3·3, 2·2-4·8) or physical abuse (30% vs 12%; 3·9, 2·2-7·2). An association with stressful life events preceding onset (OR 2·8, 95% CI 1·4-6·0) was stronger in studies with better methods (interviews; 4·3, 1·4-13·2). Heterogeneity was significant between studies (I2 21·1-90·7%). 13 studies that specifically ascertained that the participants had not had either severe life events or any subtype of maltreatment all found a proportion of patients with functional neurological disorder reporting no stressor. INTERPRETATION Stressful life events and maltreatment are substantially more common in people with functional neurological disorder than in healthy controls and patient controls. Emotional neglect had a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This outcome supports changes to diagnostic criteria in DSM-5; stressors, although relevant to the cause in many patients, are not a core diagnostic feature. This result has implications for ICD-11. FUNDING None.
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Affiliation(s)
- Lea Ludwig
- Department of Clinical Psychology and Psychotherapy, Universität Hamburg, Hamburg, Germany; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joëlle A Pasman
- Developmental Psychopathology, Radboud University, Nijmegen, Netherlands
| | - Timothy Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | - Selma Aybek
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK; Laboratory for Behavioral Neurology and Imaging of Cognition, Fundamental Neurosciences Department, Geneva University, Geneva, Switzerland
| | - Anthony S David
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | - Sharon Tuck
- Epidemiology and Statistics Core, Edinburgh Clinical Research Facility, Edinburgh, UK
| | - Richard A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, VIC, Australia; Florey Institute for Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Karin Roelofs
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands; Donders Institute for Brain Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Alan Carson
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK; Department of Rehabilitation Medicine, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Jon Stone
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Jalilianhasanpour R, Williams B, Gilman I, Burke MJ, Glass S, Fricchione GL, Keshavan MS, LaFrance WC, Perez DL. Resilience linked to personality dimensions, alexithymia and affective symptoms in motor functional neurological disorders. J Psychosom Res 2018; 107:55-61. [PMID: 29502765 PMCID: PMC5856107 DOI: 10.1016/j.jpsychores.2018.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/11/2018] [Accepted: 02/11/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Reduced resilience, a construct associated with maladaptive stress coping and a predisposing vulnerability for Functional Neurological Disorders (FND), has been under-studied compared to other neuropsychiatric factors in FND. This prospective case-control study investigated self-reported resilience in patients with FND compared to controls and examined relationships between resilience and affective symptoms, personality traits, alexithymia, health status and adverse life event burden. METHODS 50 individuals with motor FND and 47 healthy controls participated. A univariate test followed by a logistic regression analysis investigated group-level differences in Connor-Davidson Resilience Scale (CD-RISC) scores. For within-group analyses performed separately in patients with FND and controls, univariate screening tests followed by multivariate linear regression analyses examined factors associated with self-reported resilience. RESULTS Adjusting for age, gender, education status, ethnicity and lifetime adverse event burden, patients with FND reported reduced resilience compared to controls. Within-group analyses in patients with FND showed that individual-differences in mental health, extraversion, conscientiousness, and openness positively correlated with CD-RISC scores; post-traumatic stress disorder symptom severity, depression, anxiety, alexithymia and neuroticism scores negatively correlated with CD-RISC scores. Extraversion independently predicted resilience scores in patients with FND. In control subjects, univariate associations were appreciated between CD-RISC scores and gender, personality traits, anxiety, alexithymia and physical health; conscientiousness independently predicted resilience in controls. CONCLUSION Patients with FND reported reduced resilience, and CD-RISC scores covaried with other important predisposing vulnerabilities for the development of FND. Future research should investigate if the CD-RISC is predictive of clinical outcomes in patients with FND.
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Affiliation(s)
- Rozita Jalilianhasanpour
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Isabelle Gilman
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew J Burke
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sean Glass
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory L Fricchione
- Department of Psychiatry, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Rhode Island Hospital, Departments of Psychiatry and Neurology, Brown University, Alpert Medical School, Providence, RI, USA
| | - David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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77
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Garcin B. Motor functional neurological disorders: An update. Rev Neurol (Paris) 2018; 174:203-211. [DOI: 10.1016/j.neurol.2017.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/26/2022]
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DeLaroche AM, Sivaswamy L, Farooqi A, Kannikeswaran N. Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway. Pediatr Neurol 2018; 80:35-41. [PMID: 29429783 DOI: 10.1016/j.pediatrneurol.2017.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute stroke protocols improve delivery of care but it is unclear whether these resource intensive protocols are able to differentiate stroke from mimics in children. The aim of this study is to describe our institution's experience with stroke mimics identified through our pediatric stroke clinical pathway (PSCP). METHODS The PSCP was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. For patients managed using the PSCP from June 2014 to December 2016, demographic and clinical data were compared for patients diagnosed with stroke or a stroke mimic. RESULTS A total of 59 children were evaluated with the PSCP. Fourteen children were identified as having a stroke and 45 children had stroke mimics. The most common stroke mimics were functional neurological disorders (20.0%), transient neurological deficits (17.8%), migraine (15.6%), and seizure (11.1%). Patient demographics and time to neuroimaging did not differ between patients with and without stroke. Vomiting was commonly reported by patients with stroke (odds ratio: 4.00, 95% confidence interval: 1.12 to 14.35), whereas weakness was not (odds ratio: 0.7, 95% confidence interval: 0.07 to 0.90), but the physical examination did not differ between patients with and without stroke. CONCLUSIONS The PSCP ensures timely evaluation of patients presenting with neurological deficits but fails to reliably differentiate between patients with stroke and patients with stroke mimics. Further multicentered studies are needed to develop a "stroke screen" that reliably distinguishes pediatric stroke from its mimics.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
| | - Lalitha Sivaswamy
- Division of Neurology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Pastore A, Pierri G, Fabio G, Ferramosca S, Gigante A, Superbo M, Pellicciari R, Margari F. Differences in psychopathology and behavioral characteristics of patients affected by conversion motor disorder and organic dystonia. Neuropsychiatr Dis Treat 2018; 14:1287-1295. [PMID: 29849460 PMCID: PMC5965383 DOI: 10.2147/ndt.s151695] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Typically, the diagnosis of conversion motor disorder (CMD) is achieved by the exclusion of a wide range of organic illnesses rather than by applying positive criteria. New diagnostic criteria are highly needed in this scenario. The main aim of this study was to explore the use of behavioral features as an inclusion criterion for CMD, taking into account the relationship of the patients with physicians, and comparing the results with those from patients affected by organic dystonia (OD). PATIENTS AND METHODS Patients from the outpatient Movement Disorder Service were assigned to either the CMD or the OD group based on Fahn and Williams criteria. Differences in sociodemographics, disease history, psychopathology, and degree of satisfaction about care received were assessed. Patient-neurologist agreement about the etiological nature of the disorder was also assessed using the k-statistic. A logistic regression analysis estimated the discordance status as a predictor to case/control status. RESULTS In this study, 31 CMD and 31 OD patients were included. CMD patients showed a longer illness life span, involvement of more body regions, higher comorbidity with anxiety, depression, and borderline personality disorder, as well as higher negative opinions about physicians' delivering of proper care. Contrary to our expectations, CMD disagreement with neurologists about the etiological nature of the disorder was not statistically significant. Additional analysis showed that having at least one personality disorder was statistically associated with the discordance status. CONCLUSION This study suggests that CMD patients show higher conflicting behavior toward physicians. Contrary to our expectations, they show awareness of their psychological needs, suggesting a possible lack of recognition of psychological distress in the neurological setting.
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Affiliation(s)
- Adriana Pastore
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Grazia Pierri
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Giada Fabio
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Silvia Ferramosca
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Angelo Gigante
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Maria Superbo
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Roberta Pellicciari
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Margari
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Bari, Italy
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Zutt R, Gelauff J, Smit M, van Zijl J, Stone J, Tijssen M. The presence of depression and anxiety do not distinguish between functional jerks and cortical myoclonus. Parkinsonism Relat Disord 2017; 45:90-93. [DOI: 10.1016/j.parkreldis.2017.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/24/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
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81
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Perez DL, Williams B, Matin N, LaFrance WC, Costumero-Ramos V, Fricchione GL, Sepulcre J, Keshavan MS, Dickerson BC. Corticolimbic structural alterations linked to health status and trait anxiety in functional neurological disorder. J Neurol Neurosurg Psychiatry 2017; 88:1052-1059. [PMID: 28844071 DOI: 10.1136/jnnp-2017-316359] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/04/2017] [Accepted: 07/18/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Affective symptoms influence health status (health-related quality of life) in functional neurological disorder (FND), and the salience network is implicated in the pathophysiology of FND and mood/anxiety disorders. We hypothesised that self-reported health status and affective symptoms would map onto salience network regions and that patients with FND would show decreased insular volumes compared with controls. METHODS This voxel-based morphometry study investigated volumetric differences in 26 patients with FND (21 women, 5 men; mean age=40.3±11.5) compared with 27 healthy controls (22 women, 5 men; mean age=40.5±10.8). Post hoc analyses stratified patients with FND by mental and physical health scores (Short Form Health Survey-36). Within-group analyses investigated associations with mental health, physical health, trait anxiety and depression in patients with FND. RESULTS There were no volumetric differences between the complete FND cohort and controls. In stratified analyses, however, patients with FND reporting the most severe physical health impairments showed reduced left anterior insular volume compared with controls. In within-group analyses, impaired mental health and elevated trait anxiety were associated with increased right amygdalar volumes in patients with FND. The relationship between amygdalar volume and mental health, driven by emotional well-being deficits and role limitations due to emotional problems, was independent of sensorimotor functional neurological symptom severity and motor FND subtype. In secondary within-group analyses, increased periaqueductal grey volume was associated with role limitations due to emotional problems. Impaired physical functioning correlated with decreased left anterior insular volumes. CONCLUSIONS These findings support roles for several regions of the salience network in the pathophysiology of FND.
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Affiliation(s)
- David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nassim Matin
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Alpert Medical School, Providence, Rhode Island, USA
| | - Victor Costumero-Ramos
- Department of Methodology, University of Valencia, Valencia, Spain.,Department of Basic and Clinical Psychology and Psychobiology, University Jaume I, Castellón de la Plana, Spain
| | - Gregory L Fricchione
- Department of Psychiatry, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jorge Sepulcre
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bradford C Dickerson
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA.,Department of Neurology, Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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82
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Petrović IN, Tomić A, Vončina MM, Pešić D, Kostić VS. Characteristics of two distinct clinical phenotypes of functional (psychogenic) dystonia: follow-up study. J Neurol 2017; 265:82-88. [DOI: 10.1007/s00415-017-8667-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 11/29/2022]
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83
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Defazio G, Pastore A, Pellicciari R, Pierri G, Gigante AF, Fabio G, Superbo M, Margari F. Personality disorders and somatization in functional and organic movement disorders. Psychiatry Res 2017; 257:227-229. [PMID: 28780279 DOI: 10.1016/j.psychres.2017.07.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 05/30/2017] [Accepted: 07/29/2017] [Indexed: 11/17/2022]
Abstract
Psychiatric disturbances and somatizations are both criteria which support the diagnosis of functional movement disorders. It is unclear, however, whether these factors are helpful in differentiating functional and organic movement disorders. To address this issue, the Structured Clinical Interview for DSM-IV Axis I and II psychiatric disorders, the State-Trait Anxiety Inventory, the Beck Depression Inventory and the "somatization section" of the Dissociative Disorders Interview Schedule were administered to 31 functional movement disorder patients diagnosed, according to Fahn and Williams criteria and 31 sex- and age-matched control outpatients, with adult-onset dystonia. Axis I psychiatric diagnoses were similarly frequent in patients with functional and organic movement disorders. There was a trend to a greater frequency of personality disorders overall; when looking at individual personality disorders, there was no significant between-group difference. Depression and anxiety scores and mean number of somatizations per patient were also greater in the functional group. The number of somatic complaints significantly correlated with depression and anxiety scores. However, the presence of these disturbances in a proportion of patients with organic dystonia indicates that personality disorders and somatizations do not aid in distinguishing functional and organic movement disorders.
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Affiliation(s)
- Giovanni Defazio
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Adriana Pastore
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Roberta Pellicciari
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy; Department of Neurology and Psychiatry, "Sapienza", University of Rome, Rome, Italy.
| | - Grazia Pierri
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Angelo F Gigante
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Giada Fabio
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Maria Superbo
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Francesco Margari
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, "Aldo Moro", University of Bari, Bari, Italy
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Ghosh D. A 2-Year-Old Girl with Functional Dystonia Manifesting as Forceful Finger Flexion Producing Fixed Posture of Clenched Hands. Mov Disord Clin Pract 2017; 4:893-894. [PMID: 30713983 PMCID: PMC6353386 DOI: 10.1002/mdc3.12532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/10/2017] [Accepted: 07/19/2017] [Indexed: 11/11/2022] Open
Abstract
View Supplementary Video 1
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Affiliation(s)
- Debabrata Ghosh
- Department of Pediatrics and NeurologyNationwide Children's HospitalOhio State University Medical CenterOhio State UniversityColumbusOhioUSA
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85
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Perez DL, Matin N, Williams B, Tanev K, Makris N, LaFrance WC, Dickerson BC. Cortical thickness alterations linked to somatoform and psychological dissociation in functional neurological disorders. Hum Brain Mapp 2017; 39:428-439. [PMID: 29080235 DOI: 10.1002/hbm.23853] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/21/2017] [Accepted: 10/10/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Links between dissociation and functional neurological disorder (FND)/conversion disorder are well-established, yet the pathophysiology of dissociation remains poorly understood. This MRI study investigated structural alterations associated with somatoform and psychological dissociation in FND. We hypothesized that multimodal, paralimbic cingulo-insular regions would relate to the severity of somatoform dissociation in patients with FND. METHODS FreeSurfer cortical thickness and subcortical volumetric analyses were performed in 26 patients with motor FND and 27 matched healthy controls. Patients with high dissociation as measured by the Somatoform Dissociation Questionnaire-20 (SDQ) or Dissociative Experiences Scale (DES) were compared to controls in stratified analyses. Within-group analyses were also performed with SDQ and DES scores in patients with FND. All cortical thickness analyses were whole-brain corrected at the cluster-wise level. RESULTS Patients with FND and high somatoform dissociation (SDQ > 35) showed reduced left caudal anterior cingulate cortex (ACC) cortical thickness compared to controls. In within-group analyses, SDQ scores inversely correlated with left caudal ACC cortical thickness in patients with FND. Depersonalization/derealization scores positively correlated with right lateral occipital cortical thickness. Both within-group findings remained statistically significant controlling for trait anxiety/depression, borderline personality disorder and post-traumatic stress disorder, adverse life events, and motor FND subtypes in post-hoc analyses. CONCLUSION Using complementary between-group and within-group analyses, an inverse association between somatoform dissociation and left caudal ACC cortical thickness was observed in patients with FND. A positive relationship was also appreciated between depersonalization/derealization severity and cortical thickness in visual association areas. These findings advance our neuropathobiological understanding of dissociation in FND. Hum Brain Mapp 39:428-439, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Nassim Matin
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kaloyan Tanev
- Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Nikos Makris
- Center for Morphometric Analysis, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Rhode Island Hospital, Departments of Psychiatry and Neurology, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Bradford C Dickerson
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts.,Department of Neurology, Frontotemporal Disorders Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Orso R, Creutzberg KC, Centeno-Silva A, Carapeços MS, Levandowski ML, Wearick-Silva LE, Viola TW, Grassi-Oliveira R. NFκB1 and NFκB2 gene expression in the prefrontal cortex and hippocampus of early life stressed mice exposed to cocaine-induced conditioned place preference during adolescence. Neurosci Lett 2017; 658:27-31. [DOI: 10.1016/j.neulet.2017.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 08/09/2017] [Accepted: 08/13/2017] [Indexed: 11/29/2022]
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88
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Garcin B, Mesrati F, Hubsch C, Mauras T, Iliescu I, Naccache L, Vidailhet M, Roze E, Degos B. Impact of Transcranial Magnetic Stimulation on Functional Movement Disorders: Cortical Modulation or a Behavioral Effect? Front Neurol 2017; 8:338. [PMID: 28769869 PMCID: PMC5515822 DOI: 10.3389/fneur.2017.00338] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Recent studies suggest that repeated transcranial magnetic stimulation (TMS) improves functional movement disorders (FMDs), but the underlying mechanisms are unclear. The objective was to determine whether the beneficial action of TMS in patients with FMDs is due to cortical neuromodulation or rather to a cognitive-behavioral effect. Method Consecutive patients with FMDs underwent repeated low-frequency (0.25 Hz) magnetic stimulation over the cortex contralateral to the symptoms or over the spinal roots [root magnetic stimulation (RMS)] homolateral to the symptoms. The patients were randomized into two groups: group 1 received RMS on day 1 and TMS on day 2, while group 2 received the same treatments in reverse order. We blindly assessed the severity of movement disorders before and after each stimulation session. Results We studied 33 patients with FMDs (dystonia, tremor, myoclonus, Parkinsonism, or stereotypies). The median symptom duration was 2.9 years. The magnetic stimulation sessions led to a significant improvement (>50%) in 22 patients (66%). We found no difference between TMS and RMS. Conclusion We suggest that the therapeutic benefit of TMS in patients with FMDs is due more to a cognitive-behavioral effect than to cortical neuromodulation.
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Affiliation(s)
- Béatrice Garcin
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France
| | - Francine Mesrati
- Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Cécile Hubsch
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Thomas Mauras
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Psychiatry Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Iulia Iliescu
- Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France.,Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Marie Vidailhet
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France
| | - Emmanuel Roze
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France
| | - Bertrand Degos
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,CNRS-UMR 7241/INSERM U1050, CIRB, Collège de France, UPMC, Paris, France
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89
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Hallett M. The most promising advances in our understanding and treatment of functional (psychogenic) movement disorders. Parkinsonism Relat Disord 2017; 46 Suppl 1:S80-S82. [PMID: 28709746 DOI: 10.1016/j.parkreldis.2017.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/07/2017] [Indexed: 11/30/2022]
Abstract
The name functional rather than psychogenic is getting to be more widely used for terminology of this condition. It is better accepted by patients and keeps an open mind in searching for greater understanding of the pathophysiology. Advances in the pathophysiology show an overactive limbic system with connections to the motor system. Moreover, there is a disruption of the self-agency network, possibly due to a failure of feedforward signaling. There has recently been more success in treating patients. The strongest evidence is for intensive physical therapy coupled with at least some psychological support. Psychotherapy with cognitive behavioral therapy may well also be useful.
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Affiliation(s)
- Mark Hallett
- Human Motor Control Section, NINDS, NIH, Building 10, Room 7D37, 10 Center Drive, Bethesda, MD 20892-1428, USA.
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90
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Ekanayake V, Kranick S, LaFaver K, Naz A, Webb AF, LaFrance WC, Hallett M, Voon V. Personality traits in psychogenic nonepileptic seizures (PNES) and psychogenic movement disorder (PMD): Neuroticism and perfectionism. J Psychosom Res 2017; 97:23-29. [PMID: 28606495 PMCID: PMC5572831 DOI: 10.1016/j.jpsychores.2017.03.018] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/25/2017] [Accepted: 03/25/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Psychogenic movement disorder (PMD) and psychogenic nonepileptic seizures (PNES) are two subtypes of conversion disorder (CD). In this case-control study, we asked whether these subtypes varied as a function of personality and history of childhood abuse. METHODS Fifty-nine patients with PMD from the Human Motor Control Section Clinic at the National Institutes of Health, 43 patients with PNES from the Rhode Island Hospital Neuropsychiatry and Behavioral Neurology Division, and 26 healthy volunteers (HC) received a battery of neurological, psychiatric and psychological assessments, including the NEO Personality Inventory Revised (NEO PI-R), the Childhood Trauma Questionnaire (CTQ), and the Traumatic Life Events Questionnaire (TLEQ). RESULTS One-way ANOVA between the three groups indicated significant differences in overall domains of Neuroticism (p=0.001) and Conscientiousness (p=0.009): Patients with PNES reported significantly greater levels of Neuroticism (p=0.002) and lower levels of Conscientiousness (p=0.023) than patients with PMD. Levels of Neuroticism remained significantly higher in both PMD and PNES than HC following correction for multiple comparisons. Patients with PNES reported greater levels of depressive and anxiety symptoms, overall psychopathology, greater history of sexual abuse, greater levels of alexithymia, higher levels of dissociative symptoms, and an earlier age at which they experienced their most distressing traumatic event than patients with PMD. CONCLUSIONS These findings suggest that personality traits, type of abuse and age of onset of trauma varies as a function of CD subtype. Patients with PNES rated greater Neuroticism and lower Conscientiousness than patients with PMD. These differing psychological profiles may inform differing treatment approaches such as psychological therapies for PNES and physiotherapy (with/without psychotherapy) for PMD.
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Affiliation(s)
- Vindhya Ekanayake
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Sarah Kranick
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Kathrin LaFaver
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Arshi Naz
- Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence RI, USA
| | - Anne Frank Webb
- Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence RI, USA
| | - W. Curt LaFrance
- Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence RI, USA,Departments of Psychiatry and Neurology, Brown University, Providence RI, USA
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Valerie Voon
- Department of Psychiatry, University of Cambridge, Cambridge, UK,Department of Psychiatry, Addenbrookes Hospital, Level E4, Box 189, Cambridge UK, CB2 0QQ
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91
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Is there a specific psychiatric background or personality profile in functional dystonia? J Psychosom Res 2017; 97:58-62. [PMID: 28606500 DOI: 10.1016/j.jpsychores.2017.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/18/2017] [Accepted: 04/10/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this cross-sectional study was to identify if there was a specific difference between patients with functional dystonia (DysF) and those with adult-onset, isolated idiopathic ("primary") dystonia (DysP) in terms of psychiatric disorders, psychological stressor, dissociation correlates, and personality traits. METHODS Thirty-nine clinically definite DysF and 30 DysP patients matched by age, gender and dystonia distribution underwent psychiatric interview based on DSM-5 criteria and additional testings for global cognitive and psychiatric functions (Mini-Mental State Examination, Hamilton Depression and Hamilton Anxiety Rating Scale, Apathy Scale, Somatoform Dissociation Questionnaire-20, Dissociative Experiences Scale II, and the five-dimensional Revised Neuroticism-Extroversion-Openness Personality Inventory). RESULTS Almost half of our DysF patients had prior psychiatric treatment, which was significantly more frequent when compared to DysP. Patients with DysF in comparison to DysP also had considerably more frequent preceding stress, higher apathy, dissociative and somatoform scores, as well as significantly higher rate of la belle indifférence sign. This sign, stress before dystonia and prior psychiatric disorder independently predicted having DysF. Some of psychiatric disorders (i.e. substance-related disorders, schizophrenia, adjustment disorder, borderline personality disorder, post-traumatic stress disorder, psychotic depression, delusional disorder) were exclusively present among DysF patients. DysF compared to DysP patients had lower scores for both extroversion and openness to experiences. CONCLUSION Our data found different pattern of psychiatric comorbidity and personality traits between DysF and DysP patients, including a higher prevalence of psychological stressor and dissociative correlates, indicating at least a partial role of psychological mechanisms in the pathogenesis of DysF.
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92
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Impaired sense of agency in functional movement disorders: An fMRI study. PLoS One 2017; 12:e0172502. [PMID: 28448504 PMCID: PMC5407819 DOI: 10.1371/journal.pone.0172502] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/06/2017] [Indexed: 11/19/2022] Open
Abstract
The sense of agency (SA) is an established framework that refers to our ability to exert and perceive control over our own actions. Having an intact SA provides the basis for the human perception of voluntariness, while impairments in SA are hypothesized to lead to the perception of movements being involuntary that may be seen many neurological or psychiatric disorders. Individuals with functional movement disorders (FMD) experience a lack of control over their movements, yet these movements appear voluntary by physiology. We used fMRI to explore whether alterations in SA in an FMD population could explain why these patients feel their movements are involuntary. We compared the FMD group to a control group that was previously collected using an ecologically valid, virtual-reality movement paradigm that could modulate SA. We found selective dysfunction of the SA neural network, whereby the dorsolateral prefrontal cortex and pre-supplementary motor area on the right did not respond differentially to the loss of movement control. These findings provide some of the strongest evidence to date for a physiological basis underlying these disabling disorders.
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93
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Preliminary Predictors of Initial Attendance, Symptom Burden, and Motor Subtype in a US Functional Neurological Disorders Clinic Population. Cogn Behav Neurol 2017; 29:197-205. [PMID: 27984257 DOI: 10.1097/wnn.0000000000000106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS. METHODS We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes. RESULTS The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS. CONCLUSIONS In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.
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95
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van Meerkerk-Aanen PJ, de Vroege L, Khasho D, Foruz A, van Asseldonk JT, van der Feltz-Cornelis CM. La belle indifférence revisited: a case report on progressive supranuclear palsy misdiagnosed as conversion disorder. Neuropsychiatr Dis Treat 2017; 13:2057-2067. [PMID: 28814874 PMCID: PMC5546807 DOI: 10.2147/ndt.s130475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Since the advent of computed tomography and magnetic resonance imaging scans, neurological disorders have less often been falsely labeled as conversion disorder (CD). However, misdiagnosis of a neurological disorder as CD still occurs, especially in cases with insidious onset. Misinterpretation of la belle indifférence may contribute to such misdiagnosis. Here, we describe a case of progressive supranuclear palsy/Richardson's syndrome (PSPS) misdiagnosed as a case of CD. CASE A 62-year-old woman consulted two different neurologists in 2012 because of falling spells since 2009 and was diagnosed with CD. She was referred to the Clinical Center of Excellence for Body, Mind, and Health for treatment of CD. After neurological examination, blood tests, and psychiatric examination, in which la belle indifférence and a history of incest were found, CD was confirmed. However, despite treatment for CD, the patient's physical symptoms deteriorated over a year. After repeated physical and psychiatric examinations, neurocognitive assessment, and consultation with a third neurologist because of suspicion of neurological disease, the patient was diagnosed with PSPS. CONCLUSION La belle indifférence may be a psychological sign in the context of CD, but it may also be an expression of lack of mimic due to Parkinsonism or of eye movement disorder in the context of neurological illness. A diagnosis of CD should not be considered definitive if no improvement occurs in terms of physical, mental, and cognitive symptoms despite appropriate therapy. In case of deterioration, neurological reexamination and reinterpretation of la belle indifférence should be considered.
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Affiliation(s)
| | - Lars de Vroege
- Clinical Center of Excellence for Body, Mind, and Health, GGz Breburg.,Department Tranzo, Tilburg School of Behavioral and Social Sciences, Tilburg University
| | - David Khasho
- Clinical Center of Excellence for Body, Mind, and Health, GGz Breburg
| | - Aziza Foruz
- Clinical Center of Excellence for Body, Mind, and Health, GGz Breburg
| | | | - Christina M van der Feltz-Cornelis
- Clinical Center of Excellence for Body, Mind, and Health, GGz Breburg.,Department Tranzo, Tilburg School of Behavioral and Social Sciences, Tilburg University
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96
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Zutt R, Elting J, van der Hoeven J, Lange F, Tijssen M. Myoclonus subtypes in tertiary referral center. Cortical myoclonus and functional jerks are common. Clin Neurophysiol 2017; 128:253-259. [DOI: 10.1016/j.clinph.2016.10.093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/23/2016] [Accepted: 10/23/2016] [Indexed: 12/29/2022]
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97
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Sharma VD, Jones R, Factor SA. Psychodynamic Psychotherapy for Functional (Psychogenic) Movement Disorders. J Mov Disord 2016; 10:40-44. [PMID: 28122424 PMCID: PMC5288661 DOI: 10.14802/jmd.16038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/21/2016] [Accepted: 11/29/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE As the literature for the treatment of functional (psychogenic) movement disorders (FMD) is sparse, we assessed clinical outcomes in patients with FMD who underwent treatment with psychodynamic psychotherapy (PDP). METHODS A retrospective analysis of the data of patients with FMD who were referred for PDP from 2008-2014 at Emory University Medical Center was performed. RESULTS Thirty patients were included, mean age at presentation was 50 years (SD 13.9) and majority were female (27/30). Most common movement disorder was involuntary shaking/jerky movements (50%) and tremor (43%). Mean duration of symptoms was 3.2 years and mean number of PDP visits was 4.9. PDP lead to good outcomes in 10, modest in 8, and poor in 9. Three patients lost to follow up. Mean duration of symptoms between two groups (good vs. poor) was not statistically significant (p = 0.11), mean number of PDP visits showed a trend towards significance (p = 0.053). In all cases of good outcomes precipitants of the movement disorder were identified and a majority (60%) was receptive of the diagnosis and had good insight. CONCLUSION PDP lead to improvement in 60% of the patients which is encouraging as the treatment is challenging. This study supports heterogeneous causes of FMD including varied roles of past/recent events and demonstrates importance of psychological approaches such as PDP. Treatment with PDP should be considered in some patients with FMD but predicting who will respond remains a challenge. Further long term prospective studies with large sample size and placebo control are needed.
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Affiliation(s)
- Vibhash D Sharma
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Randi Jones
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Stewart A Factor
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Epstein SA, Maurer CW, LaFaver K, Ameli R, Sinclair S, Hallett M. Insights into Chronic Functional Movement Disorders: The Value of Qualitative Psychiatric Interviews. PSYCHOSOMATICS 2016; 57:566-575. [PMID: 27377316 PMCID: PMC5086310 DOI: 10.1016/j.psym.2016.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with functional movement disorders (FMDs) are commonly seen by neurologists and psychosomatic medicine psychiatrists. Research literature provides scant information about the subjective experiences of individuals with this often chronic problem. OBJECTIVE To enhance our understanding of psychologic aspects of FMDs by conducting qualitative interviews of research subjects. METHODS In total, 36 patients with FMDs were recruited from the Human Motor Control clinic at the National Institutes of Health. Each subject participated in a qualitative psychiatric interview and a structured diagnostic psychiatric interview. RESULTS Of our 36 subjects, 28 had current or lifetime psychiatric disorders in addition to conversion disorder and 22 had current disorders. Qualitative interviews provided rich information on patients' understanding of their illnesses and impaired cognitive processing of emotions. CONCLUSION Our study supports the addition of open-ended qualitative interviews to delineate emotional dynamics and conceptual frameworks among such patients. Exploratory interviews generate enhanced understanding of such complex patients, above and beyond that gained by assessing DSM diagnostic comorbidities.
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Affiliation(s)
- Steven A. Epstein
- Georgetown University School of Medicine and MedStar Health, Department of Psychiatry, Washington, DC
| | - Carine W. Maurer
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Kathrin LaFaver
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
- University of Louisville, Department of Neurology, Louisville, KY
| | - Rezvan Ameli
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Stephen Sinclair
- Section on Affective Cognitive Neuroscience, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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Newby R, Alty J, Kempster P. Functional dystonia and the borderland between neurology and psychiatry: New concepts. Mov Disord 2016; 31:1777-1784. [PMID: 27753149 DOI: 10.1002/mds.26805] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/21/2016] [Accepted: 08/29/2016] [Indexed: 01/07/2023] Open
Abstract
Mind-brain dualism has dominated historical commentary on dystonia, a dichotomous approach that has left our conceptual grasp of it stubbornly incomplete. This is particularly true of functional dystonia, most diagnostically challenging of all functional movement disorders, in which the question of inherent psychogenicity remains a focus of debate. Phenomenological signs considered in isolation lack the specificity to distinguish organic and nonorganic forms, and dystonia's variability has frustrated attempts to develop objective laboratory-supported standards. Diagnostic criteria for functional dystonia that place emphasis on psychiatric symptoms perform poorly in studies of reliability, partly explained by the high frequency of psychopathology in organic dystonia. Novel approaches from the cognitive neurosciences may offer a way forward. Theory on Bayesian statistical prediction in cognitive processing is supported by sufficient experimental evidence for this model to be taken seriously as a way of reconciling contradictory notions about voluntary and unconscious motor control in functional movement disorders. In a Bayesian formulation of functional dystonia, misallocation of attention and abnormal predictive beliefs generate movements that are executed without a sense of agency. Building on this framework, there is a consensus that a biopsychosocial approach is required and that a unified philosophy of brain and mind is the best way to locate dystonia in the neurology-psychiatry borderland. At a practical level, movement disorder neurologists are best placed to differentiate organic from functional dystonia. The main role of psychiatrists is in the diagnosis and management of the primarily psychiatric disorders that often accompany dystonia. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Rachel Newby
- Neurosciences Department, Monash Medical Centre, Clayton, Victoria, Australia.,Department of Neurology, Leeds General Infirmary, Leeds, UK
| | - Jane Alty
- Department of Neurology, Leeds General Infirmary, Leeds, UK
| | - Peter Kempster
- Neurosciences Department, Monash Medical Centre, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
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100
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Wilshire CE, Ward T. Psychogenic Explanations of Physical Illness. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2016; 11:606-631. [DOI: 10.1177/1745691616645540] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In some patients with chronic physical complaints, detailed examination fails to reveal a well-recognized underlying disease process. In this situation, the physician may suspect a psychological cause. In this review, we critically evaluated the evidence for this causal claim, focusing on complaints presenting as neurological disorders. There were four main conclusions. First, patients with these complaints frequently exhibit psychopathology but not consistently more often than patients with a comparable “organic” diagnosis, so a causal role cannot be inferred. Second, these patients report a high incidence of adverse life experiences, but again, there is insufficient evidence to indicate a causal role for any particular type of experience. Third, although psychogenic illnesses are believed to be more responsive to psychological interventions than comparable “organic” illnesses, there is currently no evidence to support this claim. Finally, recent evidence suggests that biological and physical factors play a much greater causal role in these illnesses than previously believed. We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In future research, researchers need to take a wider view concerning the etiology of these illnesses.
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