Exploring therapeutic interventions for functional neurological disorders: a comprehensive scoping review

Functional Neurological Disorders (FNDs) are characterized by the symptoms experienced by the individuals but also by how they express personal experiences and concerns related to the clinical condition. Access to care programs for functional neurological symptoms appears challenging and may entail circular, self-perpetuating healthcare pathways. Given the challenging and misleading interpretations around FND, in advocating for care pathways beyond medical therapies, we designed a scoping review to map recently suggested practices and interventions. We identified 31 relevant papers published between January 2018 and December 2022. Most of the literature was gathered from the US and UK healthcare experiences, with documented interventions provided by multi-professional teams or stand-alone psychotherapists. We found different care pathways addressing either motor or non-motor manifestations. Persons with Functional Motor Disorder are more likely to be referred to physical therapy first, while Persons suffering from Non-Epileptic Seizures are to mental health services. A narrow focus was given to minor components of multimodal approaches (e.g. social workers, and occupational therapists). High heterogeneity was found between assessment instruments as well, reflecting different perspectives in selecting treatment outcomes (e.g., reduction of non-epileptic events, psychological functioning, motor symptoms). Among healthcare professionals, neurologists and (neuro)psychiatrists are typically engaged in formulating and delivering diagnoses, while treatment is often administered by physiotherapists and/or psychologists. In the context of FNDs, the complex etiopathological nature of the condition, including comorbidities, suggests the recommendation of multidisciplinary treatments adopting a stepped care model progressing from standard to higher level individualized modules may better suit individual complexities.

Prolonged Exposure Therapy in the Treatment of Functional Neurological Disorder and Posttraumatic Stress Disorder

Functional neurological disorder (FND) symptoms resemble neurological symptoms but are unexplained by disease or injury to the body. Psychological trauma and posttraumatic stress disorder (PTSD) are prevalent among patients with FND. This is a case report of a 64-year-old female who began treatment 2 years after developing PTSD, generalised anxiety disorder, major depressive disorder and agoraphobia following a physical assault. She subsequently developed FND approximately 18 months later. Her FND symptomology was characterised by aphasia and paraplegia. These symptoms usually lasted for a period of hours to days and usually occurred on a weekly basis. She had not previously engaged in psychological therapy due to limited insight into the relationship between her psychological and physiological symptomology. She was treated with Prolonged Exposure for PTSD (PE), and by the last session, she no longer met the diagnostic criteria for either FND or PTSD disorder. PE successfully treated both PTSD and FND. Theoretical understandings of the mechanisms underpinning this improvement are discussed.

Shame in patients with psychogenic nonepileptic seizure: A narrative review

Psychogenic Nonepileptic Seizures (PNES) have been linked to dysregulated emotions and arousal. However, the question which emotions may be most relevant has received much less attention. In this multidisciplinary narrative review, we argue that the self-conscious emotion of shame is likely to be of particular importance for PNES. We summarize current concepts of the development of shame processing and its relationship with other emotional states. We demonstrate the potential of acute shame to cause a sudden disruption of normal cognitive function and trigger powerful behavioral, cognitive, physiological and secondary emotional responses which closely resemble key components of PNES. These responses may lead to the development of shame avoidance strategies which can become disabling in themselves. We discuss how excessive shame proneness and shame dysregulation are linked to several psychopathologies often associated with PNES (including depression and PTSD) and how they may predispose to, precipitate and perpetuate PNES disorders, not least by interacting with stigma. We consider current knowledge of the neurobiological underpinnings of shame and PNES. We explore how shame could be the link between PNES and a heterogeneous range of possible etiological factors, and how it may link historical aversive experiences with individual PNES events occurring much later and without apparent external trigger. We argue that, in view of the potential direct links between shame and PNES, the well-documented associations of shame with common comorbidities of this seizure disorder and the well-characterized relationship between chronic shame and stigma, there is a compelling case to pay greater attention to shame in relation to PNES. Its role in the treatment of patients with PNES is discussed in a separate, linked review incorporating case vignettes to highlight the complex interactions of different but interlinked shame-related issues in individual patients.

Using evidence-based psychotherapy to tailor treatment for patients with functional neurological disorders

Functional neurological disorder (FND) frequently presents with comorbid psychopathology (e.g., anxiety, depressive, post-traumatic stress disorders (PTSD), somatic symptom and pain syndromes, and dissociative and personality disorders). It can become chronic and lead to unemployment and disability for many patients. Psychosocial factors play an important role in the onset and perpetuation of symptoms. Consequently, psychotherapy is recommended for the treatment of FND in general, and especially for the single symptom-based subtype of functional seizures (FS). Some of the psychotherapy approaches that have been utilized for FND include cognitive-behavioral therapy (CBT), third wave approaches, and psychodynamic psychotherapies as well as group therapeutic and psychoeducational interventions. For patients with FS and PTSD, prolonged exposure therapy, a CBT-based treatment has been implemented. The purpose of this manuscript is to describe and analyze specific elements (e.g., theoretical foundations, tools, targets, definitions of success) of the main psychotherapeutic approaches used in patients with FND. Our premise is that these modalities will overlap considerably in some respects. We will conclude by discussing how discrete differences may render them more suitable for subgroups of patients with FND or for patients at different timepoints of their recovery process.

Sex Effects on Coping, Dissociation, and PTSD in Patients With Non-epileptic Seizures

PURPOSE OF REVIEW

Sex differences in non-epileptic seizures (NES) are of interest, as the diagnosis is more frequent in women than men (3:1 ratio). This paper reviews clinical findings regarding sex differences in NES through selective literature review and compares coping measures between women and men in our NES clinic.

RECENT FINDINGS

Some distinguishing clinical features of NES in women and men are reported in the literature. However, we found few sex differences in demographics and coping. In our population, avoidance and dissociation were strongly related to one another and significantly related to co-occurring PTSD diagnosis, which was seen in over 50% in both sexes. Our findings confirm a high prevalence of PTSD in patients with NES, suggesting that comorbid PTSD may override sex differences in accounting for use of avoidant and dissociative coping. These findings raise the possibility that NES may, at times, represent an extreme variant in dysfunctional coping in patients with PTSD.

The Prevalence of Posttraumatic Stress Disorder Among Survivors After a Typhoon or Hurricane: A Systematic Review and Meta-Analysis

Posttraumatic stress disorder (PTSD) is a psychological disorder, which could be caused by traumatic events. The prevalence of PTSD among survivors after a typhoon or hurricane varied widely. Therefore, this study aimed to determine a combined prevalence of PTSD among survivors after a typhoon or hurricane. A systematic search of literature was performed in the 3 English databases: PubMed (National Library of Medicine, Bethesda, MD), ISI Web of Science (Thomson Reuters, New York, NY), and Embase (Elsevier, Amsterdam, Netherlands). Also, a similar search was performed in the 2 Chinese databases such as Chinese National Knowledge Infrastructure and WanFang. Loney et al.'s criteria were used to evaluate the quality of the selected articles for this study. The combined prevalence of PTSD among the study population was estimated using the Freeman-Tukey double arcsine transformation method. Subgroup analyses and a meta-regression analysis were carried out to explore the origin of heterogeneity. Thirty-nine eligible articles were included in this study. They comprised 43 123 typhoon and hurricane survivors of which 9373 were diagnosed with PTSD. The combined prevalence of PTSD among this population was 17.81%. Subgroup analyses revealed that the combined prevalence of PTSD related to typhoon and hurricane Categories 5, 4, and 2 showing a corresponding decreasing tendency. About 18% of people who experienced a severe typhoon or hurricane develop PTSD with the prevalence decreasing with reduced severity of the typhoon or hurricane.

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

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