1
|
Jungilligens J, Perez DL. Predictive Processing and the Pathophysiology of Functional Neurological Disorder. Curr Top Behav Neurosci 2024. [PMID: 38755514 DOI: 10.1007/7854_2024_473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
The contemporary neuroscience understanding of the brain as an active inference organ supports that our conscious experiences, including sensorimotor perceptions, depend on the integration of probabilistic predictions with incoming sensory input across hierarchically organized levels. As in other systems, these complex processes are prone to error under certain circumstances, which may lead to alterations in their outcomes (i.e., variations in sensations and movements). Such variations are an important aspect of functional neurological disorder, a complex disorder at the interface of brain-mind-body interactions. Thus, predictive processing frameworks offer fundamental mechanistic insights into the pathophysiology of functional neurological disorder. In recent years, many of the aspects relevant to the neurobiology of functional neurological disorder - e.g., aberrant motor and sensory processes, symptom expectation, self-agency, and illness beliefs, as well as interoception, allostasis, and emotion - have been investigated through the lens of predictive processing frameworks. Here, we provide an overview of the current state of research on predictive processing and the pathophysiology of functional neurological disorder.
Collapse
Affiliation(s)
- Johannes Jungilligens
- Behavioral Neurology Research Group, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - David L Perez
- Division of Behavioral Neurology and Integrated Brain Medicine, Department of Neurology, Functional Neurological Disorder Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Kozlowska K, Scher S. Recent advances in understanding the neurobiology of pediatric functional neurological disorder. Expert Rev Neurother 2024; 24:497-516. [PMID: 38591353 DOI: 10.1080/14737175.2024.2333390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Functional neurological disorder (FND) is a neuropsychiatric disorder that manifests in a broad array of functional motor, sensory, or cognitive symptoms, which arise from complex interactions between brain, mind, body, and context. Children with FND make up 10%-20% of presentations to neurology services in children's hospitals and up to 20% of adolescents admitted to hospital for the management of intractable seizures. AREAS COVERED The current review focuses on the neurobiology of pediatric FND. The authors present an overview of the small but growing body of research pertaining to the biological, emotion-processing, cognitive, mental health, physical health, and social system levels. EXPERT OPINION Emerging research suggests that pediatric FND is underpinned by aberrant changes within and between neuron-glial (brain) networks, with a variety of factors - on multiple system levels - contributing to brain network changes. In pediatric practice, adverse childhood experiences (ACEs) are commonly reported, and activation or dysregulation of stress-system components is a frequent finding. Our growing understanding of the neurobiology of pediatric FND has yielded important flow-on effects for assessing and diagnosing FND, for developing targeted treatment interventions, and for improving the treatment outcomes of children and adolescents with FND.
Collapse
Affiliation(s)
- Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead, NSW, Australia
- Brain Dynamics Centre, Westmead Institute of Medical Research, Westmead, NSW, Australia
- University of Sydney Medical School, Camperdown, NSW, Australia
| | - Stephen Scher
- University of Sydney Medical School, Camperdown, NSW, Australia
- Department of Psychiatry, Harvard Medical School, Belmont, MA, USA
- McLean Hospital, Belmont, MA, USA
| |
Collapse
|
3
|
Pick S, Millman LM, Ward E, Short E, Stanton B, Reinders AS, Winston JS, Nicholson TR, Edwards MJ, Goldstein LH, David AS, Chalder T, Hotopf M, Mehta MA. Unravelling the influence of affective stimulation on functional neurological symptoms: a pilot experiment examining potential mechanisms. J Neurol Neurosurg Psychiatry 2024; 95:461-470. [PMID: 37963722 DOI: 10.1136/jnnp-2023-332364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Differences in affective processing have previously been shown in functional neurological disorder (FND); however, the mechanistic relevance is uncertain. We tested the hypotheses that highly arousing affective stimulation would result in elevated subjective functional neurological symptoms (FNS), and this would be associated with elevated autonomic reactivity. The possible influence of cognitive detachment was also explored. METHOD Individuals diagnosed with FND (motor symptoms/seizures; n=14) and healthy controls (n=14) viewed Positive, Negative and Neutral images in blocks, while passively observing the stimuli ('Watch') or detaching themselves ('Distance'). The FND group rated their primary FNS, and all participants rated subjective physical (arousal, pain, fatigue) and psychological states (positive/negative affect, dissociation), immediately after each block. Skin conductance (SC) and heart rate (HR) were monitored continuously. RESULTS FNS ratings were higher after Negative compared with Positive and Neutral blocks in the FND group (p=0.002, ηp 2=0.386); however, this effect was diminished in the Distance condition relative to the Watch condition (p=0.018, ηp 2=0.267). SC and/or HR correlated with FNS ratings in the Negative-Watch and Neutral-Distance conditions (r values=0.527-0.672, p values=0.006-0.035). The groups did not differ in subjective affect or perceived arousal (p values=0.541-0.919, ηp 2=<0.001-0.015). CONCLUSIONS Emotionally significant events may exert an influence on FNS which is related to autonomic activation rather than altered subjective affect or perceived arousal. This influence may be modulated by cognitive detachment. Further work is needed to determine the relevance and neural bases of these processes in specific FND phenotypes.
Collapse
Affiliation(s)
- Susannah Pick
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Ls Merritt Millman
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Emily Ward
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Eleanor Short
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Biba Stanton
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Aat Simone Reinders
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Joel S Winston
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy R Nicholson
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Mark J Edwards
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Laura H Goldstein
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
| | - Trudie Chalder
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Matthew Hotopf
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Mitul A Mehta
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| |
Collapse
|
4
|
Charney M, Foster S, Shukla V, Zhao W, Jiang SH, Kozlowska K, Lin A. Neurometabolic alterations in children and adolescents with functional neurological disorder. Neuroimage Clin 2023; 41:103557. [PMID: 38219534 PMCID: PMC10825645 DOI: 10.1016/j.nicl.2023.103557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/22/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES In vivo magnetic resonance spectroscopy (MRS) was used to investigate neurometabolic homeostasis in children with functional neurological disorder (FND) in three regions of interest: supplementary motor area (SMA), anterior default mode network (aDMN), and posterior default mode network (dDMN). Metabolites assessed included N-acetyl aspartate (NAA), a marker of neuron function; myo-inositol (mI), a glial-cell marker; choline (Cho), a membrane marker; glutamate plus glutamine (Glx), a marker of excitatory neurotransmission; γ-aminobutyric acid (GABA), a marker of inhibitor neurotransmission; and creatine (Cr), an energy marker. The relationship between excitatory (glutamate and glutamine) and inhibitory (GABA) neurotransmitter (E/I) balance was also examined. METHODS MRS data were acquired for 32 children with mixed FND (25 girls, 7 boys, aged 10.00 to 16.08 years) and 41 healthy controls of similar age using both short echo point-resolved spectroscopy (PRESS) and Mescher-Garwood point-resolved spectroscopy (MEGAPRESS) sequences in the three regions of interest. RESULTS In the SMA, children with FND had lower NAA/Cr, mI/Cr (trend level), and GABA/Cr ratios. In the aDMN, no group differences in metabolite ratios were found. In the pDMN, children with FND had lower NAA/Cr and mI/Cr (trend level) ratios. While no group differences in E/I balance were found (FND vs. controls), E/I balance in the aDMN was lower in children with functional seizures-a subgroup within the FND group. Pearson correlations found that increased arousal (indexed by higher heart rate) was associated with lower mI/Cr in the SMA and pDMN. CONCLUSIONS Our findings of multiple differences in neurometabolites in children with FND suggest dysfunction on multiple levels of the biological system: the neuron (lower NAA), the glial cell (lower mI), and inhibitory neurotransmission (lower GABA), as well as dysfunction in energy regulation in the subgroup with functional seizures.
Collapse
Affiliation(s)
- Molly Charney
- Department of Neurology, Columbia University Irving Medical Center, New York-Presbyterian, New York, NY, USA; Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sheryl Foster
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Radiology, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Vishwa Shukla
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wufan Zhao
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam H Jiang
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW 2145, Australia; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia; Brain Dynamics Centre, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia.
| | - Alexander Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Ogrizek A, Ros T, Ludot M, Moro MR, Hatchuel Y, Gomez NG, Radjack R, Felix A. Asserting a Functional Neurological Symptom Disorder with a Complementary Diagnostic Approach: A Brief Report. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1601. [PMID: 37892264 PMCID: PMC10605693 DOI: 10.3390/children10101601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/16/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it. METHODS We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a "normal" physical presentation, while deliriously claiming to be an angel. RESULTS All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed. CONCLUSION The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach (biblical, psychoanalytical, and historical) was used to analyze the cause of this atypical presentation.
Collapse
Affiliation(s)
- Anais Ogrizek
- Department of Adult and Child Psychiatry, Martinique University Hospital, F-97200 Fort-de-France, France;
| | - Thomas Ros
- Department of Adult and Child Psychiatry, Martinique University Hospital, F-97200 Fort-de-France, France;
| | - Maude Ludot
- Department of Child Psychiatry, University of Paris, Hôpital Cochin, Maison de Solenn, F-75014 Paris, France; (M.L.); (M.-R.M.); (R.R.)
| | - Marie-Rose Moro
- Department of Child Psychiatry, University of Paris, Hôpital Cochin, Maison de Solenn, F-75014 Paris, France; (M.L.); (M.-R.M.); (R.R.)
| | - Yves Hatchuel
- Department of Pediatrics, Martinique University Hospital, F-97200 Fort-de-France, France; (Y.H.); (N.G.G.)
| | - Nicolas Garofalo Gomez
- Department of Pediatrics, Martinique University Hospital, F-97200 Fort-de-France, France; (Y.H.); (N.G.G.)
| | - Rahmeth Radjack
- Department of Child Psychiatry, University of Paris, Hôpital Cochin, Maison de Solenn, F-75014 Paris, France; (M.L.); (M.-R.M.); (R.R.)
| | - Arthur Felix
- Department of Pediatrics, Martinique University Hospital, F-97200 Fort-de-France, France; (Y.H.); (N.G.G.)
| |
Collapse
|
6
|
Weber S, Bühler J, Vanini G, Loukas S, Bruckmaier R, Aybek S. Identification of biopsychological trait markers in functional neurological disorders. Brain 2023; 146:2627-2641. [PMID: 36417451 PMCID: PMC10232283 DOI: 10.1093/brain/awac442] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 11/26/2023] Open
Abstract
Stress is a well-known risk factor to develop a functional neurological disorder, a frequent neuropsychiatric medical condition in which patients experience a variety of disabling neurological symptoms. Only little is known about biological stress regulation, and how it interacts with predisposing biological and psychosocial risk factors. Dysregulation of the hypothalamic-pituitary-adrenal axis in patients with functional neurological disorders has been postulated, but its relationship to preceding psychological trauma and brain anatomical changes remains to be elucidated. We set out to study the hypothalamic-pituitary-adrenal axis analysing the cortisol awakening response and diurnal baseline cortisol in 86 patients with mixed functional neurological symptoms compared to 76 healthy controls. We then examined the association between cortisol regulation and the severity and duration of traumatic life events. Finally, we analysed volumetric brain alterations in brain regions particularly sensitive to psychosocial stress, acting on the assumption of the neurotoxic effect of prolonged cortisol exposure. Overall, patients had a significantly flatter cortisol awakening response (P < 0.001) and reported longer (P = 0.01) and more severe (P < 0.001) emotional neglect as compared to healthy controls. Moreover, volumes of the bilateral amygdala and hippocampus were found to be reduced in patients. Using a partial least squares correlation, we found that in patients, emotional neglect plays a role in the multivariate pattern between trauma history and hypothalamic-pituitary-adrenal axis dysfunction, while cortisol did not relate to reduced brain volumes. This suggests that psychological stress acts as a precipitating psychosocial risk factor, whereas a reduced brain volume rather represents a biological predisposing trait marker for the disorder. Contrarily, an inverse relationship between brain volume and cortisol was found in healthy controls, representing a potential neurotoxic effect of cortisol. These findings support the theory of reduced subcortical volumes representing a predisposing trait factor in functional neurological disorders, rather than a state effect of the illness. In summary, this study supports a stress-diathesis model for functional neurological disorders and showed an association between different attributes of trauma history and abnormalities in hypothalamus-pituitary-adrenal axis function. Moreover, we suggest that reduced hippocampal and amygdalar volumes represent a biological 'trait marker' for functional neurological disorder patients, which might contribute to a reduced resilience to stress.
Collapse
Affiliation(s)
- Samantha Weber
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, 3010 Bern, Switzerland
| | - Janine Bühler
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
- Graduate School for Health Sciences (GHS), University of Bern, 3012 Bern, Switzerland
| | - Giorgio Vanini
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Serafeim Loukas
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Division of Development and Growth, Department of Pediatrics, University of Geneva, 1211 Geneva, Switzerland
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland
| | - Rupert Bruckmaier
- Veterinary Physiology, Vetsuisse Faculty, University of Bern, 3012 Bern, Switzerland
| | - Selma Aybek
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
- Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| |
Collapse
|
7
|
Milano BA, Moutoussis M, Convertino L. The neurobiology of functional neurological disorders characterised by impaired awareness. Front Psychiatry 2023; 14:1122865. [PMID: 37009094 PMCID: PMC10060839 DOI: 10.3389/fpsyt.2023.1122865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.
Collapse
Affiliation(s)
- Beatrice Annunziata Milano
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
- Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michael Moutoussis
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
| | - Laura Convertino
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom
- *Correspondence: Laura Convertino,
| |
Collapse
|
8
|
Janiri D, Petracca M, Moccia L, Solito M, Lo Monaco MR, Cerbarano ML, Piano C, Imbimbo I, Di Nicola M, Simonetti A, Sani G, Bentivoglio AR. Functional Movement Disorders during COVID-19: Psychological Distress, Affective Temperament and Emotional Dysregulation. J Pers Med 2023; 13:jpm13020175. [PMID: 36836408 PMCID: PMC9960146 DOI: 10.3390/jpm13020175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Background and objective: Functional movement disorders (FMD) represent a spectrum of psychosomatic symptoms particularly sensitive to stress. The COVID-19 pandemic has increased psychological distress worldwide and may have worsened FMD. The study aimed to confirm this hypothesis and to test whether in FMD there is a relationship between affective temperament, emotional dysregulation and psychological distress due to the pandemic. Methods: We recruited individuals with FMD, diagnosed them according to validated criteria and matched them with healthy controls (HC). Psychological distress and temperament were obtained using the Kessler-10 and the Temperament Evaluation of Memphis, Pisa and San Diego Autoquestionnaire, respectively. We used bootstrapped mediation analysis to test the mediator role of emotional dysregulation on the effect of temperament on psychological distress. Results: The sample consisted of 96 individuals. During the pandemic, 31.3% of the patients reported the need for urgent neurological care, and 40.6% reported a subjective worsening neurological condition. Patients with FMD presented with more psychological distress during the COVID-19 pandemic (F = 30.15, df = 1, p ≤ 0.001) than HC. They also reported more emotional dysregulation (F = 15.80, df = 1, p ≤ 0.001) and more cyclothymic traits (F = 14.84, df = 1, p ≤ 0.001). Cyclothymic temperament showed an indirect effect on COVID-19-related psychological distress, mediated by deficits in emotion regulation mechanisms (Bootstrapped LLCI = 0.41, ULCI = 2.41). Conclusion: Our results suggest that emotional dysregulation may represent a dimension mediating cyclotimic temperament response to the stressful effect of the pandemic and provide insight for developing intervention policies.
Collapse
Affiliation(s)
- Delfina Janiri
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Psychiatry and Neurology, Sapienza University of Rome, 00100 Rome, Italy
| | - Martina Petracca
- Movement Disorders Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-0630155633
| | - Lorenzo Moccia
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marcella Solito
- Movement Disorders Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Rita Lo Monaco
- Medicine of Ageing, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Luana Cerbarano
- Movement Disorders Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Carla Piano
- Movement Disorders Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Isabella Imbimbo
- Movement Disorders Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Marco Di Nicola
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Alessio Simonetti
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Gabriele Sani
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Anna Rita Bentivoglio
- Movement Disorders Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Neuroscience, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
9
|
Johnston-Devin C, Mulvogue J, Kornhaber R, McLean L, Cleary M. Pain and Mental Health. Issues Ment Health Nurs 2023; 44:79-82. [PMID: 35104195 DOI: 10.1080/01612840.2021.2024309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | - Jennifer Mulvogue
- School of Nursing, Midwifery & Social Sciences, CQUniversity, Australia
| | - Rachel Kornhaber
- School of Nursing, University of Tasmania, Sydney, NSW, Australia
| | - Loyola McLean
- Brain and Mind Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Royal North Shore Hospital, St Leonards, NSW, Australia.,Westmead Psychotherapy Program for Complex Traumatic Disorders, Western Sydney Local Health District and the Discipline of Psychiatry, The University of Sydney, Parramatta, Australia
| | - Michelle Cleary
- School of Nursing, Midwifery & Social Sciences, CQUniversity, Australia
| |
Collapse
|
10
|
Lim N, Wood N, Prasad A, Waters K, Singh-Grewal D, Dale RC, Elkadi J, Scher S, Kozlowska K. COVID-19 Vaccination in Young People with Functional Neurological Disorder: A Case-Control Study. Vaccines (Basel) 2022; 10:2031. [PMID: 36560442 PMCID: PMC9782633 DOI: 10.3390/vaccines10122031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The emergence of acute-onset functional neurological symptoms, the focus of this study, is one of three stress responses related to immunisation. This case-control study documents the experience of 61 young people with past or current functional neurological disorder (FND) in relation to the COVID-19 vaccination program in Australia. METHODS Information about the young person's/parent's choice and response pertaining to COVID-19 vaccination was collected as part of routine clinical care or FND research program follow-up. RESULTS 61 young people treated for FND (47 females, mean age = 16.22 years) and 46 healthy controls (34 females, mean age = 16.37 years) were included in the study. Vaccination rates were high: 58/61 (95.1%) in the FND group and 45/46 (97.8%) in the control group. In the FND group, 2 young people (2/61, 3.3%) presented with new-onset FND following COVID-19 vaccination; two young people with resolved FND reported an FND relapse (2/36, 5.56%); and two young people with unresolved FND (2/20, 10.0%) reported an FND exacerbation. In the control group no FND symptoms were reported. CONCLUSIONS Acute-onset FND symptoms following COVID-19 vaccination are uncommon in the general population. In young people prone to FND, COVID-19 vaccination can sometimes trigger new-onset FND, FND relapse, or FND exacerbation.
Collapse
Affiliation(s)
- Natalie Lim
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Nicholas Wood
- National Centre for Immunisation Research and Surveillance, Kids Research, Sydney Children’s Hospitals Network, Westmead, NSW 2145, Australia
- The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Archana Prasad
- Department of General Medicine, The Children’s Hospital at Westmead Clinical School, Westmead, NSW 2145, Australia
| | - Karen Waters
- Sleep Medicine, The Children’s Hospital at Westmead, Westmead Clinical School, Westmead, NSW 2145, Australia
- Specialty of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Davinder Singh-Grewal
- Specialty of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- Department of Rheumatology, Sydney Children’s Hospital Network, Westmead, NSW 2145, Australia
- School of Women’s and Children’s Health, University of New South Wales, Randwick, NSW 2031, Australia
| | - Russell C. Dale
- Kids Neuroscience Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- The Brain and Mind Centre, University of Sydney, Camperdown, NSW 2050, Australia
| | - Joseph Elkadi
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Stephen Scher
- McLean Hospital, Belmont, MA 02478, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02215, USA
- Speciality of Psychiatry, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
- The Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- Specialty of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
- Brain Dynamics Centre at Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| |
Collapse
|
11
|
Slovák M, Anýž J, Erlebach J, Sieger T, Forejtová Z, Fabián V, Rošíková T, Nováková L, Růžička E, Edwards MJ, Serranová T. Emotional arousal in patients with functional movement disorders: A pupillometry study. J Psychosom Res 2022; 162:111043. [PMID: 36166959 DOI: 10.1016/j.jpsychores.2022.111043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/31/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pathophysiology explanations for functional movement disorders often assume a role for emotional hyperarousal. Pupillometry is a validated method for evaluation of emotional arousal by detecting changes in pupil size in response to emotional stimuli. In a case-control study design, we aimed to study objective and subjective emotional arousal using pupillometry and affective ratings. To assess attentional engagement by affective stimuli, we used videooculographic tracking of eye movement patterns (scanpath). METHODS Twenty-five female patients with functional movement disorders (mean age: 40.9 [SD 12.7] years) and 23 age matched healthy female controls participated in the study. Using infrared high-resolution eye-tracker, both pupil size and eye movement pattern in response to emotionally charged erotic, adventure, threat, victim, and neutral pictures were recorded along with subjective ratings of emotional valence and arousal of the presented pictures. RESULTS A between-group comparison showed significantly smaller pupil dilation to adventure stimuli compared to neutral stimuli in patients compared to controls (P < 0.004, bootstrap, uncorr., adj. η2 = 0.00). No significant difference in pupillary response to other stimuli and scanpath parameters was found between the groups. Patients rated significantly lower emotional arousal to erotic pictures than controls (P < 0.001, bootstrap, uncorr., adj. η2 = 0.09). CONCLUSION This study did not find evidence of autonomous or subjective emotional hyperarousal. The mismatch between objective autonomic measures and subjective arousal ratings in patients is of pathophysiological interest and in line with recent findings of impaired interoception in functional movement disorders.
Collapse
Affiliation(s)
- Matěj Slovák
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic
| | - Jiří Anýž
- Faculty of Electrical Engineering, Czech Technical University in Prague, Department of Cybernetics, Prague, Czech Republic
| | - Jonáš Erlebach
- Faculty of Electrical Engineering, Czech Technical University in Prague, Department of Economics, Management and Humanities, Prague, Czech Republic
| | - Tomáš Sieger
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic; Faculty of Electrical Engineering, Czech Technical University in Prague, Department of Cybernetics, Prague, Czech Republic
| | - Zuzana Forejtová
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic
| | - Vratislav Fabián
- Faculty of Electrical Engineering, Czech Technical University in Prague, Department of Physics, Prague, Czech Republic
| | - Tereza Rošíková
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic
| | - Lucia Nováková
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic
| | - Evžen Růžička
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic
| | - Mark J Edwards
- Institute of Molecular and Clinical Sciences, St George's University of London, Neuroscience Research Centre, London, United Kingdom
| | - Tereza Serranová
- First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Neurology and Centre of Clinical Neuroscience, Prague, Czech Republic.
| |
Collapse
|
12
|
Jungilligens J, Paredes-Echeverri S, Popkirov S, Barrett LF, Perez DL. A new science of emotion: implications for functional neurological disorder. Brain 2022; 145:2648-2663. [PMID: 35653495 PMCID: PMC9905015 DOI: 10.1093/brain/awac204] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 05/20/2022] [Indexed: 01/11/2023] Open
Abstract
Functional neurological disorder reflects impairments in brain networks leading to distressing motor, sensory and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of functional neurological disorder has been the mechanistic and aetiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g. allostasis, predictive processing, interoception and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of functional neurological disorder and related functional somatic symptoms. In doing so, we address several themes for the functional neurological disorder field including: (i) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, 'panic attack without panic', dissociation, insecure attachment and the influential role of life experiences; (ii) re-interpret select neurobiological research findings in functional neurological disorder cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and (iii) discuss therapeutic implications. While we continue to support that functional neurological disorder is mechanistically and aetiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology and cognitive-affective neuroscience.
Collapse
Affiliation(s)
- Johannes Jungilligens
- Correspondence to: Johannes Jungilligens University Hospital Knappschaftskrankenhaus Bochum Department of Neurology In der Schornau 23-25 44892 Bochum, Germany E-mail:
| | | | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | | | | |
Collapse
|
13
|
Stager L, Morriss S, McKibben L, Grant M, Szaflarski JP, Fobian AD. Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study. Seizure 2022; 98:79-86. [PMID: 35430472 PMCID: PMC9081274 DOI: 10.1016/j.seizure.2022.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development. METHODS Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS. RESULTS Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms. CONCLUSION Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.
Collapse
Affiliation(s)
- Lindsay Stager
- Department of Psychology, University of Alabama at Birmingham, United States
| | - Skylar Morriss
- Department of Psychology, University of Alabama at Birmingham, United States
| | - Lauren McKibben
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States; Department of Anesthesiology, University of North Carolina, Chapel Hill, United States
| | - Merida Grant
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States
| | - Jerzy P Szaflarski
- Departments of Neurology, Neurosurgery and Neurobiology and the UAB Epilepsy Center, University of Alabama at Birmingham, United States
| | - Aaron D Fobian
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States.
| |
Collapse
|
14
|
Kim YN, Gray N, Jones A, Scher S, Kozlowska K. The Role of Physiotherapy in the Management of Functional Neurological Disorder in Children and Adolescents. Semin Pediatr Neurol 2022; 41:100947. [PMID: 35450664 DOI: 10.1016/j.spen.2021.100947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 12/17/2022]
Abstract
Children and adolescents with functional neurological (conversion) disorder (FND) present with symptoms of impaired motor and sensory function. FND involves complex interactions between the brain, mind, body, and lived experience of the child. The gold standard for treatment is therefore a holistic, biopsychosocial approach with multimodal interventions delivered by a multidisciplinary team. In this narrative review we examine the role of physiotherapy in managing FND in children. We searched Embase, Medline, PsycINFO, and PubMed (back to 2000) for relevant physiotherapy articles and also manually searched their reference lists. Two review articles and ten observational studies were identified. Data were extracted concerning the type of study, therapies involved, outcome measures, and comorbid mental health outcomes. FND symptoms resolved in 85% to 95% of the patients, and about two-thirds returned to full-time school after completing the multidisciplinary intervention. Ongoing mental health concerns at follow-up were associated with poorer functional outcomes. Key themes included the following: use of psychological interventions embedded in the physiotherapy intervention; integration of play, music, and dance; role of physical exercise in modulating physiological, neural, and endocrine systems; need for FND-specific outcome measures; ethical issues pertaining to randomized trials; and need to develop alternate study methodologies for assessing combined treatments. Clinical vignettes were included to highlight a range of physiotherapy interventions. In conclusion, the emerging literature suggests that physiotherapy for children with FND is a useful intervention for improving motor dysfunction and for addressing other concurrent issues such as physical deconditioning, neuroprotection, chronic pain, disturbed sleep, anxiety and depression, and resilience building.
Collapse
Affiliation(s)
- Yu-Na Kim
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicola Gray
- Department of Physiotherapy, Sydney Children's Hospital Network, NSW, Australia
| | - Anna Jones
- Advance Rehab Centre, Artarmon, NSW, Australia
| | - Stephen Scher
- Department of Psychiatry, Harvard Medical School and McLean Hospital, Belmont, MA; University of Sydney Medical School, NSW, Australia
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia; University of Sydney Medical School, NSW, Australia; Westmead Institute for Medical Research, Westmead, NSW, Australia.
| |
Collapse
|
15
|
Management of Functional Neurological Disorders (FND): Experience from a Swiss FND Clinic. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn6010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Functional neurological disorder (FND) represent a common disorder with significant socio-economic impact. In this context and alongside recent new neuroscientific insights, FND attracts a growing interest both in clinical practice and academic activities. New international recommendation and expert opinions suggest that therapy of FND should be a tailored multidisciplinary management involving the neurologist, the physiotherapist, and in most cases the psychotherapist/psychiatrist. A first decisive step is the establishment of a definitive diagnosis, based on the presence of clinical positive signs during neurological assessment together with a clear communication and explanation of the diagnosis by the neurologist. A second important step is based on individual therapeutic sessions, involving different disciplines (neurology and psychotherapy or neurology and physiotherapy). Comorbidities, such as pain or fatigue and psychiatric comorbidities (anxiety, depression, dissociation etc.) should be carefully evaluated, as they need an individualized treatment path. New FND clinics have been created worldwide over the last decades to offer such multidisciplinary settings and this article will present the experience of a first Swiss FND clinic created in 2016. The aim is to highlight in the form of a narrative review the current literature supporting the usefulness and importance of FND clinics, by reviewing the latest evidence on multidisciplinary interventions in FND.
Collapse
|
16
|
Altered resting-state neural networks in children and adolescents with functional neurological disorder. NEUROIMAGE: CLINICAL 2022; 35:103110. [PMID: 36002964 PMCID: PMC9421459 DOI: 10.1016/j.nicl.2022.103110] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/14/2022] [Accepted: 07/10/2022] [Indexed: 11/24/2022] Open
Abstract
FND in children commonly involves presentation with multiple neurological symptoms. Children with FND show wide-ranging connectivity changes in resting-state neural networks. Aberrant neural-networks changes are greater in children whose FND includes functional seizures. Subjective distress, autonomic arousal, and HPA dysregulation contribute to network changes. Children with FND (vs controls) report more subjective distress and more ACEs across the lifespan.
Objectives Previous studies with adults suggest that aberrant communication between neural networks underpins functional neurological disorder (FND). The current study adopts a data-driven approach to investigate the extent that functional resting-state networks are disrupted in a pediatric mixed-FND cohort. Methods 31 children with mixed FND and 33 age- and sex-matched healthy controls completed resting-state fMRI scans. Whole-brain independent component analysis (pFWE < 0.05) was then used to identify group differences in resting-state connectivity. Self-report measures included the Depression, Anxiety and Stress Scale (DASS-21) and Early Life Stress Questionnaire (ELSQ). Resting-state heart rate (HR) and cortisol-awakening response (CAR) were available in a subset. Results Children with FND showed wide-ranging connectivity changes in eight independent components corresponding to eight resting-state neural networks: language networks (IC6 and IC1), visual network, frontoparietal network, salience network, dorsal attention network, cerebellar network, and sensorimotor network. Children whose clinical presentation included functional seizures (vs children with other FND symptoms) showed greater connectivity decreases in the frontoparietal and dorsal attentional networks. Subjective distress (total DASS score), autonomic arousal (indexed by HR), and HPA dysregulation (attenuated/reversed CAR) contributed to changes in neural network connectivity. Children with FND (vs controls) reported more subjective distress (total DASS score) and more adverse childhood experiences (ACEs) across their lifespan. Conclusions Children with FND demonstrate changes in resting-state connectivity. Identified network alterations underpin a broad range of functions typically disrupted in children with FND. This study complements the adult literature by suggesting that FND in children and adolescents emerges in the context of their lived experience and that it reflects aberrant communication across neural networks.
Collapse
|
17
|
Boulet C, Lopez-Castroman J, Mouchabac S, Olié E, Courtet P, Thouvenot E, Abbar M, Conejero I. Stress response in dissociation and conversion disorders: A systematic review. Neurosci Biobehav Rev 2021; 132:957-967. [PMID: 34740754 DOI: 10.1016/j.neubiorev.2021.10.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/14/2021] [Accepted: 10/28/2021] [Indexed: 12/28/2022]
Abstract
Dissociative disorders (DD) and conversion disorders (CD) are frequent in general and psychiatric populations. Some evidence suggest that the hypothalamic-pituitary axis (HPA) and autonomic nervous system (ANS) are dysregulated in both disorders. We carried out a systematic review of the literature to summarize the existing knowledge on the stress response, via HPA and/or ANS, in patients with DD, CD, or dissociative symptoms. We systematically searched Medline and Web of Science using the Medical Subject Headings related to stress axis, CD, DD, and dissociative symptoms following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results suggest that in participants without psychiatric history, high cortisol secretion is related to high dissociation scores. Conversely the stress system might be blunted in patients with post-traumatic stress disorder who develop dissociative symptoms. Stress response changes seem to be associated with the emergence and persistence of dissociative and conversion disorders. Hence, monitoring the stress response and examining closely the history of stress exposure in DD and CD should be encouraged in future larger studies.
Collapse
Affiliation(s)
- Charlotte Boulet
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France
| | - Jorge Lopez-Castroman
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France; IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Stéphane Mouchabac
- Saint-Antoine Hospital Center APHP, Department of Psychiatry, iCRIN Psychiatry (Infrastructure of Clinical Research in Neurosciences-Psychiatry), Brain and Spine Institute (ICM), Sorbonne University, INSERM, CNRS, 75013, Paris, France
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Eric Thouvenot
- Department of Neurology, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Mocrane Abbar
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France
| | - Ismael Conejero
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France; IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France; Centre de Biochimie Structurale, University of Montpellier, Montpellier, France.
| |
Collapse
|
18
|
Paredes-Echeverri S, Maggio J, Bègue I, Pick S, Nicholson TR, Perez DL. Autonomic, Endocrine, and Inflammation Profiles in Functional Neurological Disorder: A Systematic Review and Meta-Analysis. J Neuropsychiatry Clin Neurosci 2021; 34:30-43. [PMID: 34711069 PMCID: PMC8813876 DOI: 10.1176/appi.neuropsych.21010025] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Functional neurological disorder (FND) is a core neuropsychiatric condition. To date, promising yet inconsistently identified neural circuit profiles have been observed in patients with FND, suggesting that gaps remain in our systems-level neurobiological understanding. As such, other important physiological variables, including autonomic, endocrine, and inflammation findings, need to be contextualized for a more complete mechanistic picture. METHODS The investigators conducted a systematic review and meta-analysis of available case-control and cohort studies of FND. PubMed, PsycINFO, and Embase databases were searched for studies from January 1, 1900, to September 1, 2020, that investigated autonomic, endocrine, and inflammation markers in patients with FND. Sixty-six of 2,056 screened records were included in the review, representing 1,699 patients; data from 20 articles were used in the meta-analysis. RESULTS Findings revealed that children and adolescents with FND, compared with healthy control subjects (HCs), have increased resting heart rate (HR); there is also a tendency toward reduced resting HR variability in patients with FND across the lifespan compared with HCs. In adults, peri-ictal HR differentiated patients with functional seizures from those with epileptic seizures. Other autonomic and endocrine profiles for patients with FND were heterogeneous, with several studies highlighting the importance of individual differences. CONCLUSIONS Inflammation research in FND remains in its early stages. Moving forward, there is a need for the use of larger sample sizes to consider the complex interplay between functional neurological symptoms and behavioral, psychological, autonomic, endocrine, inflammation, neuroimaging, and epigenetic/genetic data. More research is also needed to determine whether FND is mechanistically (and etiologically) similar or distinct across phenotypes.
Collapse
Affiliation(s)
- Sara Paredes-Echeverri
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie Maggio
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Indrit Bègue
- Adult Psychiatry Division, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
- Laboratory for Clinical and Experimental Psychopathology, Department of Psychiatry, University of Geneva, Geneva, Switzerland
| | - Susannah Pick
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, United Kingdom
| | - Timothy R. Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, United Kingdom
| | - David L. Perez
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
19
|
Baslet G, Bajestan SN, Aybek S, Modirrousta M, D Clin Psy JP, Cavanna A, Perez DL, Lazarow SS, Raynor G, Voon V, Ducharme S, LaFrance WC. Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci 2021; 33:27-42. [PMID: 32778006 DOI: 10.1176/appi.neuropsych.19120354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The American Neuropsychiatric Association's Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment. A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing). Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors. A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.
Collapse
Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Sepideh N Bajestan
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Selma Aybek
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Mandana Modirrousta
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Jason Price D Clin Psy
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Andrea Cavanna
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - David L Perez
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Shelby Scott Lazarow
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Geoffrey Raynor
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Valerie Voon
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Simon Ducharme
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - W Curt LaFrance
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| |
Collapse
|
20
|
Kozlowska K, Sawchuk T, Waugh JL, Helgeland H, Baker J, Scher S, Fobian AD. Changing the culture of care for children and adolescents with functional neurological disorder. Epilepsy Behav Rep 2021; 16:100486. [PMID: 34761194 PMCID: PMC8567196 DOI: 10.1016/j.ebr.2021.100486] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/31/2021] [Accepted: 09/15/2021] [Indexed: 01/08/2023] Open
Abstract
As members of a multidisciplinary team of professionals who treat children and adolescents with functional neurological (conversion) disorder (FND), we highlight the pressing need to develop an FND-informed culture of care that takes into account recent advances in our understanding of this group of patients. Stories of clinical encounters in health care settings from around the world-told by children and adolescents with FND, their parents, and health professionals-portray an outdated culture of care characterized by iatrogenic stigma, erosion of empathy and compassion within the clinician-patient relationship, and a lack of understanding of FND and its complex neurobiology. After a brief exploration of the outdated culture, we share our counterstories: how we and our colleagues have worked, and continue to work, to create an FND-informed culture in the health systems where we practice. We discuss the therapeutic use of child-friendly language. We also discuss a range of structural, educational, and process interventions that can be used to promote FND-informed beliefs and attitudes, FND-informed clinician-patient encounters, and FND-informed referral processes, treatment pathways, and therapeutic interventions.
Collapse
Affiliation(s)
- Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
- University of Sydney Medical School, Sydney, NSW, Australia
- Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Tyson Sawchuk
- University of Calgary, Cumming School of Medicine, Department of Pediatrics, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- Alberta Children's Hospital, Calgary, AB, Canada
| | - Jeff L Waugh
- Division of Child Neurology, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
- Division of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
| | - Helene Helgeland
- Department of Child and Adolescent Mental Health in Hospitals, Oslo University Hospital, Oslo, Norway
| | - Janet Baker
- Speech Pathology, Flinders University, Adelaide, SA, Australia
- University of Technology Sydney, Sydney, NSW, Australia
| | - Stephen Scher
- University of Sydney Medical School, Sydney, NSW, Australia
- Department of Psychiatry, Harvard Medical School and McLean Hospital, Belmont, MA, USA
| | - Aaron D Fobian
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| |
Collapse
|
21
|
Ludot M, Merlo M, Ibrahim N, Piot MA, Lefèvre H, Carles ME, Harf A, Moro MR. ["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]. Encephale 2021; 47:596-604. [PMID: 34538623 DOI: 10.1016/j.encep.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 04/02/2021] [Accepted: 04/18/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents. METHODS The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis. RESULTS A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented. CONCLUSIONS Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.
Collapse
Affiliation(s)
- M Ludot
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France.
| | - M Merlo
- Maison de Solenn, hôpital Cochin, 75014 Paris, France
| | - N Ibrahim
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France; Groupe français de recherche en médecine et santé de l'adolescent, maison de Solenn, hôpital Cochin, 75014 Paris, France
| | - M-A Piot
- Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France; Faculté de santé, UFR de médecine, université de Paris, 75006 Paris, France; Service de psychiatrie de l'enfant, de l'adolescent et du jeune adulte, institut mutualiste Montsouris, 75014 Paris, France
| | - H Lefèvre
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France; Groupe français de recherche en médecine et santé de l'adolescent, maison de Solenn, hôpital Cochin, 75014 Paris, France
| | - M-E Carles
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France
| | - A Harf
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France
| | - M R Moro
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France
| |
Collapse
|
22
|
van der Feltz-Cornelis C, Brabyn S, Ratcliff J, Varley D, Allgar V, Gilbody S, Clarke C, Lagos D. Assessment of cytokines, microRNA and patient related outcome measures in conversion disorder/functional neurological disorder (CD/FND): The CANDO clinical feasibility study. Brain Behav Immun Health 2021; 13:100228. [PMID: 34589743 PMCID: PMC8474571 DOI: 10.1016/j.bbih.2021.100228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Conversion disorder/functional neurological disorder (CD/FND) occurs often in neurological settings and can lead to long-term distress, disability and demand on health care services. Systemic low-grade inflammation might play a role, however, the pathogenic mechanism is still unknown. AIM 1) To explore the feasibility to establish and assess a cohort of CD/FND with motor symptoms, involving persons with lived experience (PPI). 2) To generate proof of concept regarding a possible role for cytokines, microRNA, cortisol levels and neurocognitive symptoms in patients with motor CD/FND. METHOD Feasibility study. RESULTS The study showed active involvement of patients despite high clinical illness burden and disability, neurocognitive symptoms, childhood adverse experiences (ACE) and current life events. The study provided valuable knowledge regarding the feasibility of conducting a study in these patients that will inform future study phases. In the sample there were elevated levels of IL6, IL12, IL17A, IFNg, TNFa and VEGF-a, suggesting systemic low-grade inflammation. Also, microRNAs involved in inflammation and vascular inflammation were correlated with TNFa and VEGFa respectively, suggesting proof of concept for an epigenetic mechanism. Owing to the COVID-19 outbreak, the patient sample was limited to 15 patients. CONCLUSION It is a novelty that this study is conducted in the clinical setting. This innovative, translational study explores stress-related SLI in CD/FND patients and the feasibility of a larger project aiming to develop new treatments for this vulnerable population. Given the positive findings, there is scope to conduct further research into the mechanism of disease in CD/FND.
Collapse
|
23
|
Ocak M, Tascanov MB, Kemer Z, Yasak İH, Fedai Ü. Examination of ECG characteristics of patients admitted to emergency department with conversive attack. Am J Emerg Med 2021; 48:110-113. [PMID: 33873057 DOI: 10.1016/j.ajem.2021.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Conversion disorder is defined as a disorder with one or more neurological symptoms that accompany psychological conflict, suggesting a physical disorder. It has been shown that patients with conversion disorder have an imbalance in the autonomic nervous system. There are only a limited number of studies that have examined how conversion disorder is related with surface ECG parameters. The present study aimed to investigate the effects of conversion disorder on the surface ECG parameters of patients with conversion disorder admitted to the emergency department. METHODS This cross-sectional case-control study included 98 patients who were admitted to the emergency department and diagnosed with conversion disorder and 56 healthy volunteers. All patients underwent 12-derivation ECG. PR interval, P wave dispersion, duration of QRS complex, QT interval, QTc interval, frontal QRS-T angle values were calculated for all individuals. RESULTS When compared with the control group, the conversion disorder group revealed a significant difference in terms of PWD [60 (40-80) vs. 40 (40-60) P = 0.01], QT [385 (364-410) vs. 378 (354-394), P = 0.048], QTc [420 (405-430) vs. 406 (397-429), P = 0.039], and frontal QRS-T angle [25 (15-33) vs. 20 (8-35), P = 0.018]. In the multivariate linear regression analysis, conversion disorder was found to be an independent predictor for both PWD (β = 0.196, P = 0.014) and frontal QRS-T angle (β = 0.258, P = 0.011). CONCLUSION This study is the first to show that conversion disorder significantly increases QT, QTc, P wave dispersion, and frontal QRS-T angle.
Collapse
Affiliation(s)
- Metin Ocak
- Gazı State Hospital, Emergency Clinic Samsun, Turkey.
| | | | - Zeynep Kemer
- Department of Pediatry, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - İbrahim Halil Yasak
- Department of Emergency Medicine, Harran University Faculty of Medicine, Sanliurfa, Turkey
| | - Ülker Fedai
- Department of Psychiatry, Harran University Faculty of Medicine, Sanliurfa, Turkey
| |
Collapse
|
24
|
Asadi-Pooya AA, Brigo F, Kozlowska K, Perez DL, Pretorius C, Sawchuk T, Saxena A, Tolchin B, Valente KD. Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation. Epilepsy Behav 2021; 117:107903. [PMID: 33740497 DOI: 10.1016/j.yebeh.2021.107903] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 01/20/2023]
Abstract
The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.
Collapse
Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead Institute of Medical Research, University of Sydney Medical School, Sydney, NSW, Australia.
| | - David L Perez
- Functional Neurological Disorder Clinical and Research Programs, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Chrisma Pretorius
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
| | - Tyson Sawchuk
- Department of Pediatrics, Cumming School of Medicine, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada.
| | - Aneeta Saxena
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA; Functional Neurological Disorder Clinical and Research Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | - Benjamin Tolchin
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Kette D Valente
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil.
| |
Collapse
|
25
|
Sojka P, Paredes-Echeverri S, Perez DL. Are Functional (Psychogenic Nonepileptic) Seizures the Sole Expression of Psychological Processes? Curr Top Behav Neurosci 2021; 55:329-351. [PMID: 33768494 DOI: 10.1007/7854_2021_225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.
Collapse
Affiliation(s)
- Petr Sojka
- Department of Psychiatry, University Hospital Brno, Brno, Czech Republic.
| | - Sara Paredes-Echeverri
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Divisions, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology and Neuropsychiatry Divisions, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
26
|
Perez DL, Edwards MJ, Nielsen G, Kozlowska K, Hallett M, LaFrance WC. Decade of progress in motor functional neurological disorder: continuing the momentum. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-323953. [PMID: 33722822 PMCID: PMC8440656 DOI: 10.1136/jnnp-2020-323953] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 12/29/2022]
Abstract
Functional neurological disorder (FND) is a prevalent, disabling and costly condition at the neurology-psychiatry intersection. After being marginalised in the late 20th century, there has been renewed interest in this field. In this article, we review advances that have occurred over the past decade (2011-2020) across diagnosis, mechanisms, aetiologies, treatments and stigma in patients with motor FND (mFND, that is, functional movement disorder and functional limb weakness). In each content area, we also discuss the implications of recent advances and suggest future directions that will help continue the momentum of the past decade. In diagnosis, a major advance has been the emphasis on rule-in physical signs that are specific for hyperkinetic and hypokinetic functional motor symptoms. Mechanistically, greater importance has been given to determining 'how' functional neurological symptoms develop, highlighting roles for misdirected attention, expectation and self-agency, as well as abnormal influences of emotion/threat processing brain areas on motor control circuits. Aetiologically, while roles for adverse life experiences remain of interest in mFND, there is recognition of other aetiologic contributors, and efforts are needed to investigate links between aetiological factors and mechanisms. This decade has seen the first randomised controlled trials for physiotherapy, multidisciplinary rehabilitation and psychotherapy performed in the field, with consensus recommendations for physiotherapy, occupational therapy and outcome measures also published. Across patients, clinicians, healthcare systems and society, stigma remains a major concern. While challenges persist, a patient-centred integrated clinical neuroscience approach is primed to carry forward the momentum of the past decade into the future.
Collapse
Affiliation(s)
- David L Perez
- Neurology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark J Edwards
- Neuroscience Research Centre, St George's University of London, London, UK
| | - Glenn Nielsen
- Neuroscience Research Centre, St George's University of London, London, UK
| | - Kasia Kozlowska
- Westmead Institute of Medical Research, The Children's Hospital at Westmead, Sydney Medical School, Westmead, New South Wales, Australia
| | | | - W Curt LaFrance
- Psychiatry and Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| |
Collapse
|
27
|
Kasia K, Nicola G, Stephen S, Blanche S. Psychologically informed physiotherapy as part of a multidisciplinary rehabilitation program for children and adolescents with functional neurological disorder: Physical and mental health outcomes. J Paediatr Child Health 2021; 57:73-79. [PMID: 32861224 DOI: 10.1111/jpc.15122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 01/05/2023]
Abstract
AIM Children and adolescents with functional neurological disorder (FND) present with physical impairment and mental health comorbidities. Specialist physiotherapy programs for treating FND have been developed over the last two decades. This article reports outcome data from three cohorts of children treated with a multidisciplinary rehabilitation intervention - the Mind-Body Program - in which a psychologically informed physiotherapy intervention, known as the wellness approach to physiotherapy, was a key component. METHODS For three cohorts of children (n = 57, n = 60 and n = 25, respectively) treated in the Mind-Body Program, data about functional impairment and mental health concerns were collected at presentation and at follow-up (4 years, 12 months and 18 months, respectively). RESULTS Outcome data show that FND symptoms resolved in 54/57 (95%), 51/60 (85%) and 22/25 (88%) of children in the three cohorts, and that 31/57 (61%), 32/60 (53%) and 13/25 (52%) of children returned to full health and to full-time school attendance. Changes in Global Assessment of Function (GAF) were significant (t(54) = 21.60, P < 0.001; t(55) = 9.92, P < 0.001; t(24) = 6.51, P < 0.001). Outcomes were less favourable for children with chronic FND symptoms at presentation; those whose comorbid mental health disorders or other (comorbid) functional somatic symptoms did not resolve; and those who subsequently developed chronic mental health problems. CONCLUSIONS Implementation of a multidisciplinary rehabilitation intervention - with psychologically informed physiotherapy as one of the key treatment components - resulted in resolution of FND symptoms and return to health and well-being in the large majority of patients.
Collapse
Affiliation(s)
- Kozlowska Kasia
- Department of Psychological Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Psychiatry and Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, New South Wales, Australia.,The Brain Dynamics Centre, Westmead Institute for Medical Research, Sydney, New South Wales, Australia
| | - Gray Nicola
- Department of Physiotherapy, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Scher Stephen
- Discipline of Psychiatry and Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, New South Wales, Australia.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States
| | - Savage Blanche
- Department of Psychological Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| |
Collapse
|
28
|
Raieli V, D'Amico A, Piro E. Migraine in Children Under 7 Years of Age: a Review. Curr Pain Headache Rep 2020; 24:79. [PMID: 33326057 DOI: 10.1007/s11916-020-00912-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Despite the accumulation of a significant amount of data on pediatric headache, few studies have been conducted on its occurrence in children under 7 years of age. Within primary headaches in this age, migraine especially, turns out to be a disorder affecting up to 4% of the general population. An underestimate of its true prevalence can be due to lack of specific diagnostic markers, the frequent difficulty of describing pain in childhood, and the necessity of reliable parents' reports. Thus, migraine in children under 7 years of age represents an important challenge for clinicians. The objective of this manuscript is to provide a comprehensive review of epidemiologic, clinic, and therapeutic aspects of migraine in this age. RECENT FINDINGS Current literature data show that migraine has some differences, especially in clinical and therapeutic terms, in this age group compared to subsequent ages. Furthermore, some evidences showing that an early onset of migraine may play an unfavorable role in its natural history, suggest an early identification and management of migraine in younger children. Moreover, we highlight the role that factors of prenatal and perinatal development can play in the predisposition and anticipation of migraine onset. Finally, open questions related to the several undefined features of migraine in this age are reported. Migraine in this pediatric population is absolutely not rare, represents an importan clinical challenge and probably has a negative predictive role.
Collapse
Affiliation(s)
- Vincenzo Raieli
- Child Neuropsychiatry Unit- ISMEP -P.O. Cristina - ARNAS Civico, via dei Benedettini 1, Palermo, Italy.
| | - Antonina D'Amico
- Department for Health Promotion, Maternal Infant Care, Internal Medicine and Medical Specialties "G. D'Alessandro," Child Neuropsychiatry School, University Hospital "P. Giaccone", Via A. Giordano 3, 90127, Palermo, Italy
| | - Ettore Piro
- Department for Health Promotion, Maternal Infant Care, Internal Medicine and Medical Specialties "G. D'Alessandro," Neonatal Intensive Care Unit, University Hospital "P. Giaccone", Via A. Giordano 3, 90127, Palermo, Italy
| |
Collapse
|
29
|
Psychogenic non-epileptic seizures in children - psychophysiology & dissociative characteristics. Psychiatry Res 2020; 294:113544. [PMID: 33161178 DOI: 10.1016/j.psychres.2020.113544] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to determine psychophysiology and dissociative characteristics of psychogenic non-epileptic seizures (PNES) in a clinical pediatric setting. A retrospective chart review was conducted over a 5-year period that included children meeting criteria for probable, clinically established or documented PNES. Of these, 33 patients (81%) underwent psychophysiology assessment as part of standardized care and were selected for study inclusion. Ages ranged from 10 to 17 years inclusive (70% female). The majority of patients were found to have some form of autonomic decompensation at baseline (82%) and lack of autonomic recovery from a cognitive stressor (58%). Inhibition of electrodermal skin response to laboratory stressor was associated with significantly longer duration of PNES illness (t=2.65, p=.013), while elevated heart rate (above 90th percentile) was associated with significantly higher frequency of PNES events in the month preceding diagnosis (t=3.1, p=.004). High levels of dissociation and hyperventilation symptoms were self-reported by adolescent patients (n=19) with a moderate degree of positive association (r=0.35, p=.038). The majority of patients (n= 25, 89%) were taught to correct respiratory CO2 levels during a single biofeedback training session. Conclusions: Child PNES populations appear to be characterized by chronic autonomic hyperarousal reflecting severity of their symptoms, which can feasibly be targeted for behavioral treatment.
Collapse
|
30
|
Cretton A, Brown RJ, LaFrance WC, Aybek S. What Does Neuroscience Tell Us About the Conversion Model of Functional Neurological Disorders? J Neuropsychiatry Clin Neurosci 2020; 32:24-32. [PMID: 31619119 DOI: 10.1176/appi.neuropsych.19040089] [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] [Indexed: 11/30/2022]
Abstract
A dualistic mind-body understanding of functional neurological disorders (FNDs), also known as conversion disorders, has led to the view that the cause of the symptom should be either psychological (psychogenic) or physical (neurogenic-"organic"). One of the most influential psychological approaches is the Freudian model of conversion, which suggests that FNDs arise from a defense process in which emotional stress is converted into physical symptoms. This conversion theory has been challenged in recent years, accompanied by a shift in emphasis toward neuropathophysiological models of FND and away from historical psychological concepts. In this review, the authors consider the contemporary relevance of the conversion model from the neuroscientific perspective to reconcile the role of both psychological and biological factors in FND. A narrative review of recent neuroscientific findings pertaining to the conversion model of FND, encompassing neuroimaging, cognitive psychology, biological markers, and epigenetic studies, was performed. Research on the role of psychological stressors is discussed. Neurobiological mechanisms of repression of traumatic memories and their translation into physical symptoms are then explored. Finally, the role of physical symptoms as a potential protective defense mechanism against social stressors is considered. The authors argue that the conversion concept is consistent with recent neuroscientific research findings, and the model allows psychological and neurobiological concepts to be reconciled within a single account of FND that begins to resolve the dualistic mind-body dichotomy.
Collapse
Affiliation(s)
- Alexandre Cretton
- The Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland (Cretton, Aybek); the School of Health Sciences, University of Manchester, Manchester, United Kingdom (Brown); Manchester Academic Health Sciences Centre, Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, United Kingdom (Brown); and the Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Richard J Brown
- The Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland (Cretton, Aybek); the School of Health Sciences, University of Manchester, Manchester, United Kingdom (Brown); Manchester Academic Health Sciences Centre, Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, United Kingdom (Brown); and the Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - W Curt LaFrance
- The Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland (Cretton, Aybek); the School of Health Sciences, University of Manchester, Manchester, United Kingdom (Brown); Manchester Academic Health Sciences Centre, Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, United Kingdom (Brown); and the Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Selma Aybek
- The Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland (Cretton, Aybek); the School of Health Sciences, University of Manchester, Manchester, United Kingdom (Brown); Manchester Academic Health Sciences Centre, Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, United Kingdom (Brown); and the Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| |
Collapse
|
31
|
Radmanesh M, Jalili M, Kozlowska K. Activation of Functional Brain Networks in Children With Psychogenic Non-epileptic Seizures. Front Hum Neurosci 2020; 14:339. [PMID: 33192376 PMCID: PMC7477327 DOI: 10.3389/fnhum.2020.00339] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/03/2020] [Indexed: 02/03/2023] Open
Abstract
Objectives Psychogenic non-epileptic seizures (PNES) have been hypothesized to emerge in the context of neural networks instability. To explore this hypothesis in children, we applied a graph theory approach to examine connectivity in neural networks in the resting-state EEG in 35 children with PNES, 31 children with other functional neurological symptoms (but no PNES), and 75 healthy controls. Methods The networks were extracted from Laplacian-transformed time series by a coherence connectivity estimation method. Results Children with PNES (vs. controls) showed widespread changes in network metrics: increased global efficiency (gamma and beta bands), increased local efficiency (gamma band), and increased modularity (gamma and alpha bands). Compared to controls, they also had higher levels of autonomic arousal (e.g., lower heart variability); more anxiety, depression, and stress on the Depression Anxiety and Stress Scales; and more adverse childhood experiences on the Early Life Stress Questionnaire. Increases in network metrics correlated with arousal. Children with other functional neurological symptoms (but no PNES) showed scattered and less pronounced changes in network metrics. Conclusion The results indicate that children with PNES present with increased activation of neural networks coupled with increased physiological arousal. While this shift in functional organization may confer a short-term adaptive advantage-one that facilitates neural communication and the child's capacity to respond self-protectively in the face of stressful life events-it may also have a significant biological cost. It may predispose the child's neural networks to periods of instability-presenting clinically as PNES-when the neural networks are faced with perturbations in energy flow or with additional demands.
Collapse
Affiliation(s)
| | - Mahdi Jalili
- School of Engineering, RMIT University, Melbourne, VIC, Australia
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia.,The University of Sydney School of Medicine, Sydney, NSW, Australia.,Westmead Institute for Medical Research, Sydney, NSW, Australia
| |
Collapse
|
32
|
Heart rate variability in patients with somatic symptom disorders and functional somatic syndromes: A systematic review and meta-analysis. Neurosci Biobehav Rev 2020; 112:336-344. [DOI: 10.1016/j.neubiorev.2020.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/19/2020] [Accepted: 02/08/2020] [Indexed: 01/11/2023]
|
33
|
Psychogenic nonepileptic seizures in children-Prospective validation of a clinical care pathway & risk factors for treatment outcome. Epilepsy Behav 2020; 105:106971. [PMID: 32126506 DOI: 10.1016/j.yebeh.2020.106971] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/14/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to prospectively validate a care pathway for psychogenic nonepileptic seizures (PNES) in a pediatric setting. The pathway was developed based on a previous study of patients at our center, which demonstrated positive treatment outcomes of 80% full or partial remission. Sequentially referred patients with PNES in the validation cohort received care prospectively according to the pathway algorithm. It was hypothesized that the validation cohort would achieve outcomes similar to that of the development cohort as a result of standardized care. METHOD We performed a retrospective chart review of 43 children sequentially referred, assessed, and treated within a specialized neurology psychology service for suspected PNES over a 5-year period. The majority of patients (n = 41, 95%) met diagnostic criteria for probable, clinically established, or documented PNES, according to the International League Against Epilepsy (ILAE) criteria. RESULTS Ages ranged from 6 to 18 years of age at time of diagnosis, with the majority of patients being female (n = 29, 67%) and adolescent (n = 31, 72%). There was a high level of adherence to the care algorithm (n = 34, 84%). The development and validation cohorts were similar across demographic, clinical, and psychological characteristics. Standardized care resulted in high rates of full (n = 27, 63%) and partial (n = 12, 28%) remission, as self-reported at discharge. A 96% decrease in mean monthly frequency of total PNES events was also observed at discharge, as was a significant reduction in healthcare utilization related to PNES (74% fewer ambulance calls and 85% fewer emergency department (ED) visits). Post hoc analyses demonstrated that duration of PNES illness longer than 12 months (at diagnosis) increased odds of not achieving full remission by discharge (odds ratio = 5.94, p = 0.02). Developmental period of onset (child versus adolescent), having abnormal electroencephalogram (EEG) result, previous concussion, chronic versus acute stressor, more than one PNES event type, or additional functional neurological symptoms did not significantly impact treatment response. CONCLUSIONS This study demonstrates, for the first time prospectively in a pediatric setting, that standardized care for PNES leads to improved clinical outcomes and reduced healthcare utilization. Delayed diagnosis and treatment of PNES longer than 12 months also appears to be associated with less favorable outcomes in children.
Collapse
|
34
|
Sawchuk T, Asadi-Pooya AA, Myers L, Valente KD, Restrepo AD, D' Alessio L, Homayoun M, Bahrami Z, Alessi R, Paytan AA, Kochen S, Taha F, Lazar LM, Pick S, Nicholson TR, Buchhalter J. Clinical characteristics of psychogenic nonepileptic seizures across the lifespan: An international retrospective study. Epilepsy Behav 2020; 102:106705. [PMID: 31785480 DOI: 10.1016/j.yebeh.2019.106705] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/12/2019] [Accepted: 11/11/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Previous studies from a few countries have reported semiological differences in younger children compared with adolescents or adults with psychogenic nonepileptic seizures (PNESs). This study tested the hypothesis that semiological, demographic, and historical risk factors vary with different ages of PNES onset in a large cohort from different countries. METHODS In this retrospective study, we investigated patients consecutively referred for PNES, who were admitted to epilepsy monitoring units in Iran, Brazil, Venezuela, Canada, Argentina, and USA. Age, gender, age at seizure onset, seizure semiology, and factors predisposing to PNES (abuse, stressors) were documented according to routine diagnostic practices at each center. Participants were grouped according to their age at onset (i.e., childhood, adolescence, or adulthood). RESULTS A total of 448 patients were studied. Female predominance was associated with adolescent- (85/122, 70%) and adult-onset (190/270, 70%) but not in childhood-onset PNES (28/56, 50%) (p = 0.011). Event frequency in the month preceding the diagnosis was higher in the childhood- [x¯ = 50, standard deviation (sd) = 82, p = 0.025] versus adolescent- (x¯ = 24, sd = 36) or adult-onset groups (x¯ = 29, sd = 61). Significant between-group differences were observed for generalized body movements (p = 0.0001) and ictal injury (p = 0.027), suggesting more severe ictal presentations in adult-onset PNES compared with younger ages. Adult-onset patients were also more likely to be taking an unnecessary antiepileptic medication (p = 0.010). CONCLUSION While PNES may present at any age, there appear to be notable differences across the lifespan with respect to some of the clinical characteristics. Further international and cross-cultural studies may reveal other interesting characteristics of PNES.
Collapse
Affiliation(s)
- Tyson Sawchuk
- Children's Comprehensive Epilepsy Center, Alberta Children's Hospital, Calgary, Canada; University of Nicosia, School of Social Sciences, Department of Psychology, Cyprus.
| | - Ali A Asadi-Pooya
- Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lorna Myers
- Northeast Regional Epilepsy Group, New York, USA.
| | - Kette D Valente
- Laboratory of Clinical Neurophysiology, Institute and Department of Psychiatry, Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo (USP), Sao Paulo, Brazil.
| | - Anilu Daza Restrepo
- Laboratory of Clinical Neurophysiology, Institute and Department of Psychiatry, Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo (USP), Sao Paulo, Brazil
| | | | - Maryam Homayoun
- Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Bahrami
- Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Rudá Alessi
- Laboratory of Clinical Neurophysiology, Institute and Department of Psychiatry, Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo (USP), Sao Paulo, Brazil
| | | | - Silvia Kochen
- Buenos Aires University, Epilepsy Center, Ramos Mejía and el Cruce Hospitals, ENyS-IBCN-CONICET, Buenos Aires, Argentina
| | - Firas Taha
- Northeast Regional Epilepsy Group, New York, USA; Hackensack University Medical Center, Hackensack Meridian School of Medicine, NJ, USA.
| | - Lorraine M Lazar
- Northeast Regional Epilepsy Group, New York, USA; Hackensack University Medical Center, Hackensack Meridian School of Medicine, NJ, USA.
| | - Susannah Pick
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, Kings' College London, London, UK.
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, Kings' College London, London, UK.
| | - Jeffrey Buchhalter
- Children's Comprehensive Epilepsy Center, Alberta Children's Hospital, Calgary, Canada; University of Nicosia, School of Social Sciences, Department of Psychology, Cyprus; University of Calgary, Cumming School of Medicine, Departments of Pediatrics, Canada
| |
Collapse
|
35
|
McInnis PM, Braund TA, Chua ZK, Kozlowska K. Stress-system activation in children with chronic pain: A focus for clinical intervention. Clin Child Psychol Psychiatry 2020; 25:78-97. [PMID: 31364391 DOI: 10.1177/1359104519864994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Accumulating evidence indicates that psychological and neurophysiological processes interconnect and interact to activate the body's stress system and to trigger and maintain functional somatic symptoms. This study used the Early Life Stress Questionnaire, Depression Anxiety Stress Scales and biological markers (heart rate, heart rate variability, skin conductance, C-reactive protein (CRP) titre, respiratory rate, and accuracy and reaction time in an emotion-face identification task), to examine childhood adversity, psychological distress and stress-system activation in 35 children and adolescents (23 girls and 12 boys, 9-17 years old) disabled by chronic pain (vs two groups of age- and sex-matched healthy controls). Patients reported more early-life stress (U = 798.5, p = .026) and more psychological distress (U = 978, p < .001). They showed activation of the autonomic system: elevated heart rate (U = 862.5, p = .003), elevated electrodermal activity (U = 804.5, p = .024) and lower heart rate variability in the time domain (U = 380.5, p = .007) and frequency domain (U = 409.5, p = .017). The group showed an upward shift of CRP titres (with 75th and 90th CRP percentiles of 4.5 and 10.5 mg/L, respectively), suggesting the activation of the immune-inflammatory system. Elevated CRP titres were associated with elevated heart rate (p = .028). There were no differences in respiratory rate or in accuracy and reaction time in the emotion-face identification task. The results indicate that interventions for children and adolescents with chronic pain need a multidisciplinary mind-body approach that concurrently addresses psychological distress, physical impairment and stress-system dysregulation.
Collapse
Affiliation(s)
- Peter M McInnis
- Department of Psychological Medicine, The Children's Hospital at Westmead, Australia
| | - Taylor A Braund
- Total Brain, Australia.,Brain Dynamics Centre, The Westmead Institute for Medical Research, Australia.,Sydney Medical School, University of Sydney, Australia
| | - Zhi Kai Chua
- Department of Psychological Medicine, The Children's Hospital at Westmead, Australia
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Australia.,Brain Dynamics Centre, The Westmead Institute for Medical Research, Australia.,Sydney Medical School, University of Sydney, Australia
| |
Collapse
|
36
|
Pick S, Goldstein LH, Perez DL, Nicholson TR. Emotional processing in functional neurological disorder: a review, biopsychosocial model and research agenda. J Neurol Neurosurg Psychiatry 2019; 90:704-711. [PMID: 30455406 PMCID: PMC6525039 DOI: 10.1136/jnnp-2018-319201] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/20/2018] [Accepted: 10/29/2018] [Indexed: 12/13/2022]
Abstract
Functional neurological disorder (FND) is a common and highly disabling disorder, but its aetiology remains enigmatic. Conceptually, there has been reduced emphasis on the role of psychosocial stressors in recent years, with a corresponding increase in neurobiological explanations. However, a wealth of evidence supports the role of psychosocial adversities (eg, stressful life events, interpersonal difficulties) as important risk factors for FND. Therefore, there is a need to integrate psychosocial (environmental) and neurobiological factors (eg, sensorimotor and cognitive functions) in contemporary models of FND. Altered emotional processing may represent a key link between psychosocial risk factors and core features of FND. Here, we summarise and critically appraise experimental studies of emotional processing in FND using behavioural, psychophysiological and/or neuroimaging measures in conjunction with affective processing tasks. We propose that enhanced preconscious (implicit) processing of emotionally salient stimuli, associated with elevated limbic reactivity (eg, amygdala), may contribute to the initiation of basic affective/defensive responses via hypothalamic and brainstem pathways (eg, periaqueductal grey). In parallel, affect-related brain areas may simultaneously exert a disruptive influence on neurocircuits involved in voluntary motor control, awareness and emotional regulation (eg, sensorimotor, salience, central executive networks). Limbic-paralimbic disturbances in patients with FND may represent one of several neurobiological adaptations linked to early, severe and/or prolonged psychosocial adversity. This perspective integrates neurobiological and psychosocial factors in FND and proposes a research agenda, highlighting the need for replication of existing findings, multimodal sampling across emotional response domains and further examination of emotional influences on sensorimotor and cognitive functions in FND populations.
Collapse
Affiliation(s)
- Susannah Pick
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioural Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| |
Collapse
|
37
|
Kozlowska K, Chung J, Cruickshank B, McLean L, Scher S, Dale RC, Mohammad SS, Singh-Grewal D, Prabhuswamy MY, Patrick E. Blood CRP levels are elevated in children and adolescents with functional neurological symptom disorder. Eur Child Adolesc Psychiatry 2019; 28:491-504. [PMID: 30143887 DOI: 10.1007/s00787-018-1212-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/03/2018] [Indexed: 01/09/2023]
Abstract
There is accumulating evidence that patients with functional neurological symptom disorder (FND) show activation of multiple components of the stress system-the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and brain regions involved in arousal- and emotion-processing. This study aims to examine whether the immune-inflammatory component of the stress system is also activated. C-reactive protein (CRP) blood titre levels were measured in 79 children and adolescents with FND. CRP values ≥ 2 mg/L suggest low-grade inflammation. CRP values > 10 mg/L suggest a disease process. Sixty-six percent of subjects (n = 52) had CRP titres ≥ 2 mg/L. The upward shift in the distribution of CRP levels suggested low-grade inflammation (median CRP concentration was 4.60 mg/L, with 75th and 90th percentiles of 6.1 and 10.3 mg/L, respectively). Elevated CRP titres were not explained by sex, pubertal status, BMI, or medical factors. Confounder analyses suggested that history of maltreatment (χ2 = 2.802, df = 1, p = 0.094, φ = 0.190; β = 2.823, p = 0.04) and a diagnosis of anxiety (χ2 = 2.731, df = 1, p = 0.098, φ = 0.187; β = 4.520, p = 0.061) contributed to elevated CRP levels. Future research will need to identify the origins and locations of immune cell activation and the pathways and systems contributing to their activation and modulation. Because functional activity in neurons and glial cells-the brain's innate effector immune cells-is tightly coupled, our finding of elevated CRP titres suggests activation of the immune-inflammatory component of the brain's stress system. A more direct examination of inflammation-related molecules in the brain will help clarify the role of immune-inflammatory processes in FND.
Collapse
Affiliation(s)
- Kasia Kozlowska
- Department Psychological Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia. .,Brain Dynamics Centre, Westmead Institute of Medical Research, Westmead, NSW, Australia. .,Discipline of Psychiatry and Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, NSW, Australia.
| | - Jason Chung
- Department of Clinical Biochemistry, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia.,Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, NSW, Australia
| | - Bronya Cruickshank
- Department Psychological Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia
| | - Loyola McLean
- Westmead Psychotherapy Program for Complex Traumatic Disorders, Western Sydney Local Health District, Building 112, Cumberland Hospital Campus, Parramatta BC, Locked Bag 7118, Parramatta, NSW, 2124, Australia.,Brain and Mind Centre, and Discipline of Psychiatry, University of Sydney Medical School, Sydney, NSW, Australia
| | - Stephen Scher
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.,McLean Hospital, Belmont, MA, USA.,Discipline of Psychiatry, University of Sydney Medical School, Sydney, NSW, Australia
| | - Russell C Dale
- Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, NSW, Australia.,Movement Disorder and Clinical Neuroimmunology Group, Institute for Neuroscience and Muscle Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia
| | - Shekeeb S Mohammad
- Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, NSW, Australia.,Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia
| | - Davinder Singh-Grewal
- Discipline of Child and Adolescent Health, University of Sydney Medical School, Sydney, NSW, Australia.,Department of Rheumatology, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia.,Discipline of Child and Maternal Health, University of New South Wales, Sydney, NSW, Australia
| | - Mukesh Yajaman Prabhuswamy
- Department Psychological Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Ellis Patrick
- School of Mathematics and Statistics, University of Sydney, F07 - Carslaw Building, Sydney, NSW, 2006, Australia.,Westmead Institute for Medical Research, Sydney, NSW, Australia
| |
Collapse
|
38
|
Bègue I, Adams C, Stone J, Perez DL. Structural alterations in functional neurological disorder and related conditions: a software and hardware problem? Neuroimage Clin 2019; 22:101798. [PMID: 31146322 PMCID: PMC6484222 DOI: 10.1016/j.nicl.2019.101798] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/20/2019] [Accepted: 03/26/2019] [Indexed: 01/01/2023]
Abstract
Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A "software" vs. "hardware" analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including "disease staging" discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a "software" and "hardware" problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder.
Collapse
Affiliation(s)
- Indrit Bègue
- Department of Psychiatry, University of Geneva, Switzerland; Service of Adult Psychiatry, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland; Laboratory for Behavioral Neurology and Imaging of Cognition, Geneva Neuroscience Center, University of Geneva, Switzerland
| | - Caitlin Adams
- Functional Neurology Research Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Inpatient Psychiatry Division, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - David L Perez
- Functional Neurology Research Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.
| |
Collapse
|
39
|
Chudleigh C, Savage B, Cruz C, Lim M, McClure G, Palmer DM, Spooner CJ, Kozlowska K. Use of respiratory rates and heart rate variability in the assessment and treatment of children and adolescents with functional somatic symptoms. Clin Child Psychol Psychiatry 2019; 24:29-39. [PMID: 30354283 DOI: 10.1177/1359104518807742] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state - respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements - as a way of helping families to understand how physical symptoms can signal activation of the body's stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems.
Collapse
Affiliation(s)
- Catherine Chudleigh
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Blanche Savage
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Catherine Cruz
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Melissa Lim
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Georgia McClure
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Donna M Palmer
- 2 Brain Dynamics Centre, The Westmead Institute for Medical Research, NSW, Australia.,3 The University of Sydney, NSW, Australia
| | | | - Kasia Kozlowska
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,2 Brain Dynamics Centre, The Westmead Institute for Medical Research, NSW, Australia.,3 The University of Sydney, NSW, Australia
| |
Collapse
|
40
|
Ospina JP, Jalilianhasanpour R, Perez DL. The role of the anterior and midcingulate cortex in the neurobiology of functional neurologic disorder. HANDBOOK OF CLINICAL NEUROLOGY 2019; 166:267-279. [PMID: 31731915 DOI: 10.1016/b978-0-444-64196-0.00014-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Functional neurologic disorder (FND)/conversion disorder is a prevalent and disabling condition at the intersection of neurology and psychiatry. Clinicians often report feeling ill-equipped treating patients with FND, perpetuated by a historically limited understanding of neurobiologic disease mechanisms. In this review, we summarize the neuroimaging literature across the spectrum of sensorimotor FND, including functional imaging studies during rest, sensorimotor performance, and emotional-processing tasks as well as structural magnetic resonance imaging findings. Particular attention is given to studies implicating the anterior and middle cingulate cortex and related salience network structures (insula, amygdala, and periaqueductal gray) in the neurobiology of FND. Neuroimaging studies identify cingulo-insular functional alterations during rest, motor performance, and emotion processing in FND populations. The literature also supports that patients with FND exhibit heightened amygdalar and periaqueductal gray reactivity to emotionally valenced stimuli, enhanced coupling between amygdalar and motor control areas, and increased amygdalar volumes. The structural neuroimaging literature also implicates cingulo-insular areas in the pathophysiology of FND, though these findings require replication and clarification. While more research is needed to fully elucidate the pathophysiology of FND, salience network alterations appear present in some FND populations and can be contextualized using biopsychosocial models for FND.
Collapse
Affiliation(s)
- Juan Pablo Ospina
- Department of Neurology, Cognitive Behavioral Neurology Unit, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Rozita Jalilianhasanpour
- Department of Neurology, Cognitive Behavioral Neurology Unit, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - David L Perez
- Departments of Neurology and Psychiatry, Cognitive Behavioral Neurology and Neuropsychiatry Units, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
41
|
Laborde S, Mosley E, Mertgen A. A unifying conceptual framework of factors associated to cardiac vagal control. Heliyon 2018; 4:e01002. [PMID: 30623126 PMCID: PMC6313821 DOI: 10.1016/j.heliyon.2018.e01002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/20/2018] [Accepted: 11/29/2018] [Indexed: 11/30/2022] Open
Abstract
Cardiac vagal control (CVC) reflects the activity of the vagus nerve regulating cardiac functioning. CVC can be inferred via heart rate variability measurement, and it has been positively associated to a broad range of cognitive, emotional, social, and health outcomes. It could then be considered as an indicator for effective self-regulation, and given this role, one should understand the factors increasing and decreasing CVC. The aim of this paper is to review the broad range of factors influencing CVC, and to provide a unifying conceptual framework to integrate comprehensively those factors. The structure of the unifying conceptual framework is based on the theory of ecological rationality, while its functional aspects are based on the neurovisceral integration model. The structure of this framework distinguishes two broad areas of associations: person and environment, as this reflects adequately the role played by CVC regarding adaptation. The added value of this framework lies at different levels: theoretically, it allows integrating findings from a variety of scientific disciplines and refining the predictions of the neurovisceral integration model; methodologically, it helps identifying factors that increase and decrease CVC; and lastly at the applied level, it can play an important role for society regarding health policies and for the individual to empower one's flourishing.
Collapse
Affiliation(s)
- Sylvain Laborde
- German Sport University Cologne, Institute of Psychology, Department of Performance Psychology, Germany.,Normandie Université Caen, UFR STAPS, EA 4260, Germany
| | | | | |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Enhancing cardiac vagal activity: Factors of interest for sport psychology. PROGRESS IN BRAIN RESEARCH 2018; 240:71-92. [PMID: 30390842 DOI: 10.1016/bs.pbr.2018.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Self-regulation plays a critical role in sport performance. An objective, psychophysiological marker of self-regulation is cardiac vagal activity, the activity of the vagus nerve regulating cardiac functioning. The aim of this paper is to provide an overview of factors influencing cardiac vagal activity, which can be useful for athletes. Specifically, we organize this overview in two main domains: personal factors and environmental factors. Among the personal factors, we discuss the behavioral strategies that can be used by athletes: nutrition, non-ingestive oral habits, water immersion, body temperature reduction, sleeping habits, relaxation methods, cognitive techniques, praying, music, and exercise. Among environmental factors, we discuss those linked to the social (i.e., contact with humans and animals) and physical (i.e., aromas, lights, sounds, temperature, outdoor, altitude) environment. Future research directions are given, as well as practical implications for athletes and coaches.
Collapse
|
44
|
Luthy SK, Moss AF, Torok MR, McLeod L, Wilson KM. Characteristics of Children Hospitalized for Psychogenic Nonepileptic Seizures Due to Conversion Disorder Versus Epilepsy. Hosp Pediatr 2018; 8:321-329. [PMID: 29739840 DOI: 10.1542/hpeds.2017-0103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Psychogenic nonepileptic seizures (PNES) are a manifestation of conversion disorder among children but can be difficult to distinguish from epilepsy. We sought to identify characteristics that differentiate children with PNES from those with epilepsy. METHODS We conducted a retrospective cohort study of children admitted with epilepsy or PNES to 45 children's hospitals from 2004 to 2014. Children with PNES (n = 399) versus those with epilepsy (n = 13 241) were compared on demographic and clinical characteristics, testing, treatment, and health care use. Hierarchical multivariable logistic regression was used to identify characteristics associated with PNES diagnosis. RESULTS Children with PNES were more likely to be female (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.8-3.0), older (aOR 3.8; 95% CI 2.7-5.3 for 14-16 years old), African American (aOR 2.0; 95% CI 1.5-2.7), and have diagnosis codes for psychiatric disorders (aOR 7.1; 95% CI 5.6-9.1) and pain (aOR 2.6; 95% CI 1.9-3.4). They were also more likely to be admitted in the fall (aOR 2.0; 95% CI 1.4-2.8) or spring (aOR 1.9; 95% CI 1.4-2.6) versus summer. Total adjusted hospitalization costs were greater for children with epilepsy ($4724, 95% CI $4413-$5057 vs $5326, 95% CI $5259-$5393; P = .001); length of stay was similar. CONCLUSIONS Demographic and clinical characteristics differed among children with PNES versus those with epilepsy, including significantly increased odds of psychiatric and pain diagnoses among children with PNES. To better inform treatment and prognostication for children with PNES, research is needed to understand reasons for these differences, seasonal admission patterns, and the relationship between PNES and other psychiatric disorders.
Collapse
Affiliation(s)
- Sarah K Luthy
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela F Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado
| | - Michelle R Torok
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado
| | - Lisa McLeod
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado; and
| | - Karen M Wilson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
45
|
Kozlowska K, Spooner CJ, Palmer DM, Harris A, Korgaonkar MS, Scher S, Williams LM. "Motoring in idle": The default mode and somatomotor networks are overactive in children and adolescents with functional neurological symptoms. Neuroimage Clin 2018; 18:730-743. [PMID: 29876262 PMCID: PMC5987846 DOI: 10.1016/j.nicl.2018.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/19/2018] [Accepted: 02/02/2018] [Indexed: 12/20/2022]
Abstract
Objective Children and adolescents with functional neurological symptom disorder (FND) present with diverse neurological symptoms not explained by a disease process. Functional neurological symptoms have been conceptualized as somatoform dissociation, a disruption of the brain's intrinsic organization and reversion to a more primitive level of function. We used EEG to investigate neural function and functional brain organization in children/adolescents with FND. Method EEG was recorded in the resting eyes-open condition in 57 patients (aged 8.5-18 years) and 57 age- and sex-matched healthy controls. Using a topographical map, EEG power data were quantified for regions of interest that define the default mode network (DMN), salience network, and somatomotor network. Source localization was examined using low-resolution brain electromagnetic tomography (LORETA). The contributions of chronic pain and arousal as moderators of differences in EEG power were also examined. Results Children/adolescents with FND had excessive theta and delta power in electrode clusters corresponding to the DMN-both anteriorly (dorsomedial prefrontal cortex [dmFPC]) and posteriorly (posterior cingulate cortex [PCC], precuneus, and lateral parietal cortex)-and in the premotor/supplementary motor area (SMA) region. There was a trend toward increased theta and delta power in the salience network. LORETA showed activation across all three networks in all power bands and localized neural sources to the dorsal anterior cingulate cortex/dmPFC, mid cingulate cortex, PCC/precuneus, and SMA. Pain and arousal contributed to slow wave power increases in all three networks. Conclusions These findings suggest that children and adolescents with FND are characterized by overactivation of intrinsic resting brain networks involved in threat detection, energy regulation, and preparation for action.
Collapse
Affiliation(s)
- Kasia Kozlowska
- The Children's Hospital at Westmead, Psychological Medicine, Locked Bag 4001, Westmead, NSW 2145, Australia; The Brain Dynamics Centre, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia; The University of Sydney, Sydney, Australia.
| | | | - Donna M Palmer
- The Brain Dynamics Centre, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia; The University of Sydney, Sydney, Australia.
| | - Anthony Harris
- The Brain Dynamics Centre, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia; The University of Sydney, Sydney, Australia; Westmead Hospital Psychiatry Department, Darcy Rd, Westmead, NSW 2145, Australia.
| | - Mayuresh S Korgaonkar
- The Brain Dynamics Centre, Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia; The University of Sydney, Sydney, Australia.
| | - Stephen Scher
- The University of Sydney, Sydney, Australia; Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA.
| | - Leanne M Williams
- Psychiatry and Behavioral Sciences, Stanford University, VA Palo Alto (Sierra-Pacific MIRECC) 401 Quarry Rd, United States.
| |
Collapse
|
46
|
Stephenson CP, Baguley IJ. Functional neurological symptom disorder (conversion disorder): A role for microglial-based plasticity mechanisms? Med Hypotheses 2018; 111:41-48. [DOI: 10.1016/j.mehy.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/12/2017] [Accepted: 12/03/2017] [Indexed: 10/18/2022]
|
47
|
Kozlowska K, Chudleigh C, Cruz C, Lim M, McClure G, Savage B, Shah U, Cook A, Scher S, Carrive P, Gill D. Psychogenic non-epileptic seizures in children and adolescents: Part II - explanations to families, treatment, and group outcomes. Clin Child Psychol Psychiatry 2018; 23:160-176. [PMID: 28956479 PMCID: PMC5757408 DOI: 10.1177/1359104517730116] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Psychogenic non-epileptic seizures (PNES) - time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) - are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain - with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 ( t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES.
Collapse
Affiliation(s)
- Kasia Kozlowska
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,2 Brain Dynamics Centre at atWestmead Institute for Medical Research, NSW, Australia.,3 Sydney Medical School, The University of Sydney, NSW, Australia
| | - Catherine Chudleigh
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Catherine Cruz
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Melissa Lim
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Georgia McClure
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Blanche Savage
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Ubaid Shah
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,4 TY Nelson Department of Neurology, The Children's Hospital at Westmead, NSW, Australia.,5 Lady Cilento Children's Hospital, Queensland, Australia
| | - Averil Cook
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,6 Child and Adolescent Mental Health Service Macarthur (ICAMHS) Macarthur, NSW, Australia
| | - Stephen Scher
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,7 Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
| | - Pascal Carrive
- 8 Department of Anatomy, School of Medical Sciences, University of NSW, Australia
| | - Deepak Gill
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,4 TY Nelson Department of Neurology, The Children's Hospital at Westmead, NSW, Australia
| |
Collapse
|
48
|
Kozlowska K, Chudleigh C, Cruz C, Lim M, McClure G, Savage B, Shah U, Cook A, Scher S, Carrive P, Gill D. Psychogenic non-epileptic seizures in children and adolescents: Part I - Diagnostic formulations. Clin Child Psychol Psychiatry 2018; 23:140-159. [PMID: 28956448 PMCID: PMC5757410 DOI: 10.1177/1359104517732118] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations - the clinical formulations about the probable neurophysiological mechanisms - that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet's dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.
Collapse
Affiliation(s)
- Kasia Kozlowska
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,2 Brain Dynamics Centre at at Westmead Institute for Medical Research, NSW, Australia.,3 Sydney Medical School, The University of Sydney, NSW, Australia
| | - Catherine Chudleigh
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Catherine Cruz
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Melissa Lim
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Georgia McClure
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Blanche Savage
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Ubaid Shah
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,4 TY Nelson Department of Neurology, The Children's Hospital at Westmead, NSW, Australia.,5 Lady Cilento Children's Hospital, Queensland, Australia
| | - Averil Cook
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,6 Child and Adolescent Mental Health Service Macarthur (ICAMHS) Macarthur, NSW, Australia
| | - Stephen Scher
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,7 Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
| | - Pascal Carrive
- 8 Department of Anatomy, School of Medical Sciences, University of NSW, Australia
| | - Deepak Gill
- 3 Sydney Medical School, The University of Sydney, NSW, Australia.,4 TY Nelson Department of Neurology, The Children's Hospital at Westmead, NSW, Australia
| |
Collapse
|
49
|
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.
Collapse
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
| |
Collapse
|
50
|
Biological and perceived stress in motor functional neurological disorders. Psychoneuroendocrinology 2017; 85:142-150. [PMID: 28863348 DOI: 10.1016/j.psyneuen.2017.08.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current models explaining motor functional neurological disorders (FND) integrate both the neurobiological mechanisms underlying symptoms production and the role of psychosocial stressors. Imaging studies have suggested abnormal motor control linked to impaired emotional and stress regulation. However, little is known on the biological stress regulation in FND. Our aim was to study the biological and perceived response to stress in patients with motor FND. METHODS Sixteen patients with motor FND (DSM-5 criteria) and fifteen healthy controls underwent the Trier Social Stress Test. Hypothalamo-pituitary-adrenal axis (HPA) response was evaluated with salivary cortisol and autonomous sympathetic response with salivary alpha-amylase. Area under the curve was computed to reflect background levels (AUCg) and change over time (AUCi). Life adversities and perceived subjective stress on a visual analog scale (VAS) were correlated with biological responses. RESULTS FND patients had significantly higher background levels (AUCg) of both stress markers (cortisol and amylase) than controls. The biological response (AUCi) to stress did not differ between groups for both markers but the subjective response showed an interaction effect with patients reporting higher levels of stress than controls. After stress, controls showed a strong correlation between subjective and objective sympathetic values (amylase) but not patients. The number and subjective impact of adverse life events correlated with cortisol AUCg in patients only. CONCLUSION This study confirms a baseline HPA-axis and sympathetic hyperarousal state in motor FND related to life adversities. During a social stress, dissociation between perceived stress and biological markers was observed in patients only, reflecting a dysregulation of interoception capacity, which might represent an endophenotype of this disorder.
Collapse
|