Introducing a 'neuropsychiatry' special issue: but what does that mean?

The capacity of the BATCH as a predictive tool for discharge planning for people with neuropsychiatric disorders

BACKGROUND/AIM

Assessment of cognitive function in people with neurosychiatric disorders can be challenging, due to behavioural and psychiatric symptomatology. The Behavioural Assesment Tool for Cognition and Higher Functioning (BATCH) is a validated observational tool that complements formal cognitive testing in this patient population. This study aimed to determine the capacity of the BATCH as a predictive tool for discharge planning.

METHOD

BATCH scores for 330 consecutive admissions for assessment to a specialist neuropsychiatry unit between 2007 and 2015 were analysed. The variables of interest included discharge destination, diagnosis, length of stay, age at discharge and BATCH scores (both subdomain and total). Significant predictors of discharge destination were identified using logistic regression analysis.

RESULTS

After adjusting for age at discharge, three variables were found to be significant predictors of discharge destination - length of stay, diagnosis, and BATCH total score. The odds of being discharged to a destination other than home decreased by 3% for each additional BATCH total score unit. The length of stay remained a significant predictor of discharge destination when adjusting for BATCH total score, age at admission and diagnosis.

CONCLUSION

BATCH total scores, but not subdomain scores, were predictive of discharge destination, along with the patients' length of stay and diagnosis. Knowledge of this relationship may guide clinical discharge planning, when working with the complex needs of this group of patients. A larger study is indicated to determine the range and cut-off scores for discharge destinations other than home.

Biological and perceived stress in motor functional neurological disorders

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.

Integrated Behavioral Health Care in Pediatric Subspecialty Clinics

Comorbid behavioral and physical health conditions are accompanied by troubling symptom burden, functional impairment, and treatment complexity. Pediatric subspecialty care clinics offer an opportunity for the implementation of integrated behavioral health (BH) care models that promote resiliency. This article reviews integrated BH care in oncology, palliative care, pain, neuropsychiatry, cystic fibrosis, and transplantation. Examples include integrated care mandates, standards of care, research, and quality improvement by child and adolescent psychiatrists (CAPs) and allied BH clinicians. The role of CAPs in integrated BH care in subspecialty care is explored, focusing on cost, resource use, financial support, and patient and provider satisfaction.

Testing Head Rotation and Flexion Is Useful in Functional Limb Weakness

Background

Functional (psychogenic) neurological disorders (FNDs) are common and should be diagnosed using positive diagnostic features of internal inconsistency. However, there is a lack of objective data regarding motor signs and a lack of signs relating to motor disorders that affect the upper body and neck. The objective of this study was to provide specificity and sensitivity data on 2 axial motor signs: the sternocleidomastoid (SCM) and platysma signs.

Methods

Thirty patients with motor FNDs according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and 40 organic controls with unilateral weakness were prospectively included. The SCM functional sign and platysma organic signs were systematically tested and compared between groups.

Results

The SCM sign had high specificity of 90% (confidence interval [CI], 77%-96%) to detect FND when the platysma sign had 100% specificity (CI, 88%-100%) for detecting organic weakness. The co-occurrence of a positive SCM and a negative platysma sign in patients with unilateral weakness carried 95% specificity (CI, 83%-99%) and 63% sensitivity (CI, 44%-80%).

Conclusion

The SCM test and platysma signs can be used for the diagnosis of motor FND. The extent to which these add value to other validated signs (such as Hoover's sign) should be further evaluated.

Imaging studies of functional neurologic disorders

Brain imaging techniques provide unprecedented opportunities to study the neural mechanisms underlying functional neurologic disorder (FND, or conversion disorder), which have long remained a mystery and clinical challenge for physicians, as they arise with no apparent underlying organic disease. One of the first questions addressed by imaging studies concerned whether motor conversion deficits (e.g., hysteric paralysis) represent a form of (perhaps unconscious) simulation, a mere absence of voluntary movement, or more specific disturbances in motor control (such as abnormal inhibition). Converging evidence from several studies using different techniques and paradigms has now demonstrated distinctive brain activation patterns associated with functional deficits, unlike those seen in actors simulating similar deficits. Thus, patients with motor FND show consistent hypoactivation of both cortical and subcortical motor pathways, with frequent increases in other brain areas within the limbic system, but no recruitment of prefrontal regions usually associated with voluntary motor inhibition. Other studies point to a dysfunction in sensorimotor integration and agency - related to parietal dysfunction - and abnormal motor planning related to supplementary motor area and prefrontal areas. These findings not only suggest that functional symptoms reflect a genuine brain dysfunction, but also give new insights into how they are produced. However, fewer studies attempted to understand why these symptoms are produced and linked to potential psychologic or emotional risk/triggering factors. Results from such studies point towards abnormal limbic regulation with heightened emotional arousal and amygdalar activity, potentially related to engagement of defense systems and stereotyped motor behaviors, mediated by medial prefrontal cortex and subcortical structures, including the periaqueductal gray area and basal ganglia. In addition, across different symptom domains, several studies reported abnormal recruitment of ventromedial prefrontal cortex (vmPFC), a region known to regulate emotion appraisal, memory retrieval, and self-reflective representations. The vmPFC might provide important modulatory signals to both cortical and subcortical sensorimotor, visual, and even memory circuits, promoting maladaptive self-protective behaviors based on personal affective appraisals of particular events. A better understanding of such a role of vmPFC in FND may help link how and why these symptoms are produced. Further research is also needed to determine brain activation patterns associated with FND across different types of deficits and different evolution stages (e.g., acute vs. chronic vs. recovered).

Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and nonepileptic attacks

OBJECTIVE

The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks.

METHODS

This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models.

RESULTS

Our intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P<.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P<.05) and on the Beck Depression Inventory (P<.05)] and a reduction in new hospital stays after intervention (P<.05).

CONCLUSION

A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.