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Cabreira V, Alty J, Antic S, Araújo R, Aybek S, Ball HA, Baslet G, Bhome R, Coebergh J, Dubois B, Edwards M, Filipović SR, Frederiksen KS, Harbo T, Hayhow B, Howard R, Huntley J, Isaacs J, LaFrance WC, Larner AJ, Di Lorenzo F, Main J, Mallam E, Marra C, Massano J, McGrath ER, McWhirter L, Moreira IP, Nobili F, Pennington C, Tábuas-Pereira M, Perez DL, Popkirov S, Rayment D, Rossor M, Russo M, Santana I, Schott J, Scott EP, Taipa R, Tinazzi M, Tomic S, Toniolo S, Tørring CW, Wilkinson T, Frostholm L, Stone J, Carson A. Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study. Eur J Neurol 2024:e16318. [PMID: 38700361 DOI: 10.1111/ene.16318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/18/2024] [Accepted: 04/11/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions. METHODS International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken. RESULTS Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%-88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%-92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD. CONCLUSIONS Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions.
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Affiliation(s)
- Verónica Cabreira
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jane Alty
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia
| | - Sonja Antic
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Rui Araújo
- Department of Neurology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Porto, Portugal
| | - Selma Aybek
- Neurology, Faculty of Sciences and Medicine, Fribourg University, Fribourg, Switzerland
| | - Harriet A Ball
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rohan Bhome
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
- Centre for Medical Image Computing, University College London, London, UK
| | - Jan Coebergh
- Department of Neurology, St George's University of London, London, UK
| | - Bruno Dubois
- Department of Neurology, Institut de la mémoire et de la maladie d'Alzheimer (IM2A), AP-HP, Brain Institute, Sorbonne University, Paris, France
| | - Mark Edwards
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry Psychology and Neurosciences, Kings College London, London, UK
| | - Saša R Filipović
- University of Belgrade Institute for Medical Research, Belgrade, Serbia
| | - Kristian Steen Frederiksen
- Clinical Trial Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bradleigh Hayhow
- Department of Neurology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Jeremy Isaacs
- Department of Neurology, St George's University of London, London, UK
| | - William Curt LaFrance
- Alpert Medical School, Brown University, Providence, Rhode Island, USA
- Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Andrew J Larner
- Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Francesco Di Lorenzo
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - James Main
- Bristol Dementia Wellbeing Service, Devon Partnership NHS Trust, Bristol, UK
| | | | - Camillo Marra
- Department of Neuroscience, Catholic University of the Sacred Heart, Memory Clinic - Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - João Massano
- Department of Neurology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Porto, Portugal
| | - Emer R McGrath
- School of Medicine, University of Galway, Galway, Ireland
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Isabel Portela Moreira
- Neurology Department, Private Hospital of Gaia of the Trofa Saúde Group, Vila Nova de Gaia, Portugal
| | - Flavio Nobili
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Catherine Pennington
- Clinical Lecturer, University of Edinburgh, Edinburgh, UK
- Neurology Department, NHS Forth Valley, Larbert, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Miguel Tábuas-Pereira
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - David L Perez
- Department of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Dane Rayment
- Rosa Burden Centre for Neuropsychiatry, Southmead Hospital, Bristol, UK
| | - Martin Rossor
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Isabel Santana
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - Jonathan Schott
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Emmi P Scott
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ricardo Taipa
- Neuropathology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Svetlana Tomic
- Department of Neurology, University Hospital Center Osijek, Medical School on University of Osijek, Osijek, Croatia
| | - Sofia Toniolo
- Cognitive Disorder Clinic, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Tim Wilkinson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Lisbeth Frostholm
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Joseph A, Baslet G, O'Neal MA, Polich G, Gonsalvez I, Christoforou AN, Dworetzky BA, Spagnolo PA. Prevalence of autoimmune diseases in functional neurological disorder: influence of psychiatric comorbidities and biological sex. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-332825. [PMID: 38514177 DOI: 10.1136/jnnp-2023-332825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Functional neurological disorder (FND) is a common and disabling neuropsychiatric condition, which disproportionally affects women compared with men. While the etiopathogenesis of this disorder remains elusive, immune dysregulation is emerging as one potential mechanism. To begin to understand the role of immune dysfunctions in FND, we assessed the prevalence of several common autoimmune diseases (ADs) in a large cohort of patients with FND and examined the influence of psychiatric comorbidities and biological sex. METHODS Using a large biorepository database (Mass General Brigham Biobank), we obtained demographic and clinical data of a cohort of 643 patients diagnosed with FND between January 2015 and December 2021. The proportion of ADs was calculated overall, by sex and by the presence of psychiatric comorbidities. RESULTS The overall prevalence of ADs in our sample was 41.9%, with connective tissue and autoimmune endocrine diseases being the most commonly observed ADs. Among patients with FND and ADs, 27.7% had ≥2 ADs and 8% met criteria for multiple autoimmune syndrome. Rates of ADs were significantly higher in subjects with comorbid major depressive disorder and post-traumatic stress disorder (p= 0.02). Women represented the largest proportion of patients with concurrent ADs, both in the overall sample and in the subgroups of interest (p's < 0.05). CONCLUSIONS This study is unique in providing evidence of an association between FND and ADs. Future studies are needed to investigate the mechanisms underlying this association and to understand whether FND is characterised by distinct dysregulations in immune response.
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Affiliation(s)
- Anna Joseph
- Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gaston Baslet
- Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mary A O'Neal
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ginger Polich
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Boston, Boston, Massachusetts, USA
| | - Irene Gonsalvez
- Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea N Christoforou
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Boston, Boston, Massachusetts, USA
| | - Barbara A Dworetzky
- Harvard Medical School, Boston, Massachusetts, USA
- Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Primavera A Spagnolo
- Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Polich G, Zalanowski S, Lewis JM, Sugarman S, Christopulos K, Hebb C, Perez DL, Baslet G, Shah P, Herman S. Inpatient Rehabilitation for Acute Presentations of Motor Functional Neurological Disorder: A Retrospective Cohort Study. Am J Phys Med Rehabil 2024; 103:99-104. [PMID: 37339055 DOI: 10.1097/phm.0000000000002303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Patients with functional neurological disorder involving the motor system (eg, functional weakness, functional gait) may acutely present to the hospital for new-onset symptoms. For some, symptoms may remain severe enough at the time of hospital discharge to qualify for an inpatient rehabilitation facility stay. DESIGN Data were extracted via retrospective chart review on functional neurological disorder patients ( N = 22) admitted to an inpatient rehabilitation facility between September 2019 and May 2022. Demographic and clinical data, including admission and discharge physical and occupational therapy measurements on the Inpatient Rehabilitation Facility Patient Assessment Instrument, were recorded and analyzed. RESULTS Symptom duration was less than 1 wk for nearly two thirds of the cohort. After an approximately 2-wk length of stay, patients showed statistically significant changes in admission to discharge measures of self-care, transfers, ambulation, and balance. More than 95% of patients were able to be discharged home. The presence or absence of comorbid depression, anxiety, or posttraumatic stress disorder did not impact outcomes. CONCLUSIONS For a subset of patients with persistent motor symptoms after an acute hospital admission for a new diagnosis of functional neurological disorder, a relatively short inpatient rehabilitation facility stay was associated with significant clinical gains.
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Affiliation(s)
- Ginger Polich
- From the Spaulding Rehabilitation Hospital, Boston, Massachusetts (GP, SZ, JML, SS, KC, CH, PS); Brigham and Women's Hospital, Boston, Massachusetts (GP, GB); MedRhythms, Inc, Boston, Massachusetts (CH); Massachusetts General Hospital, Boston, Massachusetts (DLP); and California Rehabilitation Institute, Cedars Sinai Medical Center, Los Angeles, California (SH)
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4
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Finkelstein SA, O'Neal MA, Gaston Baslet, Dworetzky BA, Godena E, Maggio J, Millstein D, Milligan T, Perez DL. Developing a Curriculum for Functional Neurological Disorder in Neurology Training: Questions and Answers. Neurol Clin 2023; 41:711-728. [PMID: 37775200 DOI: 10.1016/j.ncl.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Functional neurologic disorder (FND) is a common condition for which neurology residents often receive little to no formal teaching. Using a question-and-answer format, this article puts forward a case for why an FND curriculum is needed and aims to provide guidance on possible curricular content including medical knowledge, clinical skills, communication, and team-based collaboration. The authors also discuss methods for teaching and evaluating this knowledge and associated clinical skills, linking this to current Accreditation Council for Graduate Medical Education neurology milestones. Finally, the authors consider how to better engage and energize neurology trainees around this underserved yet challenging patient population.
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Affiliation(s)
- Sara A Finkelstein
- Functional Neurological Disorder Unit, Division of Behavioral Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | - M Angela O'Neal
- Division of General Neurology, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Gaston Baslet
- Division of Neuropsychiatry, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA
| | - Barbara A Dworetzky
- Division of Epilepsy, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA
| | - Ellen Godena
- Functional Neurological Disorder Unit, Division of Behavioral Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Julie Maggio
- Functional Neurological Disorder Unit, Division of Behavioral Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Physical Therapy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Daniel Millstein
- Functional Neurological Disorder Unit, Division of Behavioral Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Tracey Milligan
- Department of Neurology, Westchester Medical Center Health Network, New York Medical College, Valhalla, NY, USA
| | - David L Perez
- Functional Neurological Disorder Unit, Division of Behavioral Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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5
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Cassady M, Baslet G. Dissociation in patients with epilepsy and functional seizures: A narrative review of the literature. Seizure 2023; 110:220-230. [PMID: 37433243 DOI: 10.1016/j.seizure.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/18/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023] Open
Abstract
Dissociation is a "disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment" according to DSM-5. It is commonly seen in psychiatric disorders including primary dissociative disorders, post-traumatic stress disorder, depression, and panic disorder. Dissociative phenomena are also described in the context of substance intoxication, sleep deprivation and medical illnesses including traumatic brain injury, migraines, and epilepsy. Patients with epilepsy have higher rates of dissociative experiences as measured on the Dissociative Experiences Scale compared to healthy controls. Ictal symptoms, especially in focal epilepsy of temporal lobe origin, may include dissociative-like experiences such as déjà vu/jamais vu, depersonalization, derealization and what has been described as a "dreamy state". These descriptions are common in the setting of seizures that originate from mesial temporal lobe epilepsy and may involve the amygdala and hippocampus. Other ictal dissociative phenomena include autoscopy and out of body experiences, which are thought to be due to disruptions in networks responsible for the integration of one's own body and extra-personal space and involve the temporoparietal junction and posterior insula. In this narrative review, we will summarize the updated literature on dissociative experiences in epilepsy, as well as dissociative experiences in functional seizures. Using a case example, we will review the differential diagnosis of dissociative symptoms. We will also review neurobiological underpinnings of dissociative symptoms across different diagnostic entities and discuss how ictal symptoms may shed light on the neurobiology of complex mental processes including the subjective nature of consciousness and self-identity.
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Affiliation(s)
- Maureen Cassady
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, McCorkell L, Nadkarni GN, Parthasarathy S, Singh U, Walker TA, Selvaggi CA, Shinnick DJ, Schulte CCM, Atchley-Challenner R, Alba GA, Alicic R, Altman N, Anglin K, Argueta U, Ashktorab H, Baslet G, Bassett IV, Bateman L, Bedi B, Bhattacharyya S, Bind MA, Blomkalns AL, Bonilla H, Bush PA, Castro M, Chan J, Charney AW, Chen P, Chibnik LB, Chu HY, Clifton RG, Costantine MM, Cribbs SK, Davila Nieves SI, Deeks SG, Duven A, Emery IF, Erdmann N, Erlandson KM, Ernst KC, Farah-Abraham R, Farner CE, Feuerriegel EM, Fleurimont J, Fonseca V, Franko N, Gainer V, Gander JC, Gardner EM, Geng LN, Gibson KS, Go M, Goldman JD, Grebe H, Greenway FL, Habli M, Hafner J, Han JE, Hanson KA, Heath J, Hernandez C, Hess R, Hodder SL, Hoffman MK, Hoover SE, Huang B, Hughes BL, Jagannathan P, John J, Jordan MR, Katz SD, Kaufman ES, Kelly JD, Kelly SW, Kemp MM, Kirwan JP, Klein JD, Knox KS, Krishnan JA, Kumar A, Laiyemo AO, Lambert AA, Lanca M, Lee-Iannotti JK, Logarbo BP, Longo MT, Luciano CA, Lutrick K, Maley JH, Marathe JG, Marconi V, Marshall GD, Martin CF, Matusov Y, Mehari A, Mendez-Figueroa H, Mermelstein R, Metz TD, Morse R, Mosier J, Mouchati C, Mullington J, Murphy SN, Neuman RB, Nikolich JZ, Ofotokun I, Ojemakinde E, Palatnik A, Palomares K, Parimon T, Parry S, Patterson JE, Patterson TF, Patzer RE, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Quigley JG, Reddy U, Reece R, Reeder H, Reeves WB, Reiman EM, Rischard F, Rosand J, Rouse DJ, Ruff A, Saade G, Sandoval GJ, Schlater SM, Shepherd F, Sherif ZA, Simhan H, Singer NG, Skupski DW, Sowles A, Sparks JA, Sukhera FI, Taylor BS, Teunis L, Thomas RJ, Thorp JM, Thuluvath P, Ticotsky A, Tita AT, Tuttle KR, Urdaneta AE, Valdivieso D, VanWagoner TM, Vasey A, Verduzco-Gutierrez M, Wallace ZS, Ward HD, Warren DE, Weiner SJ, Welch S, Whiteheart SW, Wiley Z, Wisnivesky JP, Yee LM, Zisis S, Horwitz LI, Foulkes AS. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA 2023; 329:1934-1946. [PMID: 37278994 PMCID: PMC10214179 DOI: 10.1001/jama.2023.8823] [Citation(s) in RCA: 152] [Impact Index Per Article: 152.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 06/07/2023]
Abstract
Importance SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals. Objective To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections. Design, Setting, and Participants Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling. Exposure SARS-CoV-2 infection. Main Outcomes and Measures PASC and 44 participant-reported symptoms (with severity thresholds). Results A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months. Conclusions and Relevance A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.
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Affiliation(s)
- Tanayott Thaweethai
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Bruce Levy
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Lisa McCorkell
- Patient-Led Research Collaborative, Calabasas, California
| | | | | | - Upinder Singh
- Stanford University School of Medicine, Stanford, California
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- University of Kansas Medical Center, Kansas City
| | | | | | - Peter Chen
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Helen Y Chu
- University of Washington School of Medicine, Seattle
| | | | | | | | | | | | | | | | | | | | | | | | - Cheryl E Farner
- The University of Texas Health Science Center at San Antonio
| | | | | | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | | | | | | | | | | | | | - Minjoung Go
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | - John Hafner
- University of Illinois Chicago College of Medicine
| | - Jenny E Han
- Emory University School of Medicine, Atlanta, Georgia
| | | | - James Heath
- Institute for Systems Biology, Seattle, Washington
| | | | - Rachel Hess
- University of Utah Schools of the Health Sciences, Salt Lake City
| | - Sally L Hodder
- West Virginia Clinical and Translational Science Institute, Morgantown
| | | | | | | | | | | | - Janice John
- Cambridge Health Alliance, Cambridge, Massachusetts
| | | | - Stuart D Katz
- New York University Grossman School of Medicine, New York
| | | | | | - Sara W Kelly
- University of Illinois College of Medicine at Peoria
| | | | - John P Kirwan
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago
| | - Andre Kumar
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | | | | | | - Jason H Maley
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Yuri Matusov
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Alem Mehari
- Howard University College of Medicine, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jan E Patterson
- The University of Texas Health Science Center at San Antonio
| | | | | | | | | | | | - Beth A Plunkett
- Harvard Medical School, Boston, Massachusetts
- NorthShore University HealthSystem, Evanston, Illinois
| | | | - Athena Poppas
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Uma Reddy
- Columbia University Irving Medical Center, New York, New York
| | - Rebecca Reece
- West Virginia University School of Medicine, Morgantown
| | | | - W B Reeves
- Department of Medicine, The University of Texas Health Science Center at San Antonio
| | | | | | | | | | - Adam Ruff
- The University of Kansas Medical Center, Kansas City
| | | | - Grecio J Sandoval
- Milken Institute of Public Health, The George Washington University, Washington, DC
| | | | | | - Zaki A Sherif
- Howard University College of Medicine, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Steven J Weiner
- The George Washington University Biostatistics Center, Rockville, Maryland
| | | | | | | | | | - Lynn M Yee
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Andrea S Foulkes
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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7
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Baslet G, Aybek S, Ducharme S, Modirrousta M, Nicholson TR. Neuropsychiatry's Role in the Postacute Sequelae of COVID-19: Report From the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci 2022; 34:341-350. [PMID: 35578802 DOI: 10.1176/appi.neuropsych.21080209] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Postacute sequelae of COVID-19 can occur in patients who had only mild acute disease. A comprehensive neuropsychiatric approach reviews historical factors, provides objective assessment of symptoms, considers potential etiologies, and offers a therapeutic approach aimed at restoring premorbid functioning.
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Affiliation(s)
- Gaston Baslet
- Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Bern University Hospital, Bern, Switzerland (Aybek); Department of Psychiatry, Douglas Mental Health University Institute, McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal (Ducharme); University of Manitoba, Winnipeg (Modirrousta); Institute of Psychiatry, Psychology and Neuroscience, King's College London, London (Nicholson)
| | - Selma Aybek
- Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Bern University Hospital, Bern, Switzerland (Aybek); Department of Psychiatry, Douglas Mental Health University Institute, McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal (Ducharme); University of Manitoba, Winnipeg (Modirrousta); Institute of Psychiatry, Psychology and Neuroscience, King's College London, London (Nicholson)
| | - Simon Ducharme
- Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Bern University Hospital, Bern, Switzerland (Aybek); Department of Psychiatry, Douglas Mental Health University Institute, McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal (Ducharme); University of Manitoba, Winnipeg (Modirrousta); Institute of Psychiatry, Psychology and Neuroscience, King's College London, London (Nicholson)
| | - Mandana Modirrousta
- Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Bern University Hospital, Bern, Switzerland (Aybek); Department of Psychiatry, Douglas Mental Health University Institute, McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal (Ducharme); University of Manitoba, Winnipeg (Modirrousta); Institute of Psychiatry, Psychology and Neuroscience, King's College London, London (Nicholson)
| | - Timothy R Nicholson
- Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Bern University Hospital, Bern, Switzerland (Aybek); Department of Psychiatry, Douglas Mental Health University Institute, McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal (Ducharme); University of Manitoba, Winnipeg (Modirrousta); Institute of Psychiatry, Psychology and Neuroscience, King's College London, London (Nicholson)
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8
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Polich G, Zalanowski S, Maney J, Perez DL, Baslet G, Maggio J, O’Neal MA, Dworetzky B, Herman S. Development of an inpatient rehabilitation pathway for motor functional neurological disorders: Initial reflections. NeuroRehabilitation 2022; 50:231-243. [DOI: 10.3233/nre-228006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND: Emerging research supports a primary role for rehabilitation therapy alongside psychoeducation and psychotherapy in the treatment of functional neurological disorder (FND). OBJECTIVE: While consensus recommendations for physical therapists, occupational therapists, and speech and language pathologists treating FND have been published, specific recommendations for multidisciplinary FND care delivered on an inpatient rehabilitation unit are yet to be established. METHODS: This report describes one inpatient rehabilitation facility’s efforts to design and implement a clinical pathway for patients with acute-onset motor FND—patients recently hospitalized for work-up of new neurological symptoms subsequently deemed functional. RESULTS: Detailed descriptions on defining admission criteria and delivering consensus- and evidence-based multidisciplinary inpatient rehabilitation are provided. CONCLUSIONS: In the context of prospective research studies, considerably more work is needed to delineate the optimal duration and intensity of inpatient rehabilitation treatment for the management of patients with motor FND.
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Affiliation(s)
- Ginger Polich
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Julie Maney
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - David L. Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Maggio
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Mary A. O’Neal
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Seth Herman
- Department of Physical Medicine and Rehabilitation, California Rehabilitation Institute, Los Angeles, CA, USA
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9
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Baslet G, Ridlon R, Raynor G, Gonsalvez I, Dworetzky BA. Sustained improvement with mindfulness-based therapy for psychogenic nonepileptic seizures. Epilepsy Behav 2022; 126:108478. [PMID: 34922325 DOI: 10.1016/j.yebeh.2021.108478] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND We previously reported on the efficacy of a manualized 12-session mindfulness-based therapy (MBT) for psychogenic nonepileptic seizures (PNES). Completion of MBT provided improvements in weekly PNES frequency and self-rated intensity. OBJECTIVES In this study, we aimed to determine sustainability of improvement of seizure-related measures at 3- to 6-month follow-up after treatment completion. We also examined changes at treatment end and at follow-up on therapeutic targets of the MBT program. METHODS Patients with documented PNES were recruited from 2014 to 2018. Baseline measures were collected at time of diagnosis (T0) and at first follow-up post-diagnosis (T1). Outcomes are reported at MBT treatment completion (T3) and 3- to 6-month follow-up (T4). The Wilcoxon signed-rank test was used for pair-wise comparisons of PNES frequency; linear mixed models were used for other outcomes. RESULTS Fourteen of the 26 MBT completers (54%) attended follow-up (median 147.5 days between T3 and T4). PNES frequency, intensity, and number of days/week with PNES remained reduced at T4 (p < 0.01 for all; median frequency reduction 1.3/week from T1). Illness perception and feeling understood remained improved at T4 (p < 0.001 for both) as did worry about PNES (p < 0.05). Illness attribution (physical, mental or both) changed from T0 to T3 (p < 0.01), but not to T4. Psychological flexibility did not change over time. CONCLUSION Previously reported improvements in seizure-related measures with MBT at treatment conclusion were maintained at 3- to 6-month follow-up. There were sustained improvements in some underlying processes (illness perception, feeling understood, and symptom worry) over the course of treatment and at follow-up. Long-term benefits of MBT need to be established with randomized controlled trials.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Robert Ridlon
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Geoffrey Raynor
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Irene Gonsalvez
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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10
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O'Neal MA, Dworetzky BA, Baslet G. Functional neurological disorder: Engaging patients in treatment. Epilepsy Behav Rep 2021; 16:100499. [PMID: 34877516 PMCID: PMC8633865 DOI: 10.1016/j.ebr.2021.100499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 01/04/2023] Open
Abstract
Patients with a functional neurological disorder can be difficult to engage in treatment. The reasons for this are complex and may be related to physician, patient and health care system issues. Providers contribute to difficulties in treatment engagement by giving confusing explanations for the patient symptoms, stigmatizing patients, and not allowing patients time to voice their questions and concerns. Patient factors include a lack of engagement after an explanation of the diagnosis, resistance to treatment, family/work dynamics and prior negative experiences with the health care system. The scarcity of providers skilled in the treatment of functional neurological disorder is yet another hurdle. This article will define these barriers and discuss good clinical practices to help improve outcomes by tackling those challenges and discuss why for many patients an integrated care team approach is needed.
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Affiliation(s)
- Mary A O'Neal
- Department of Neurology, Brigham and Women's Hospital, United States
| | | | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, United States
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11
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Tolchin B, Baslet G, Carson A, Dworetzky BA, Goldstein LH, LaFrance WC, Martino S, Perez DL, Reuber M, Stone J, Szaflarski JP. The role of evidence-based guidelines in the diagnosis and treatment of functional neurological disorder. Epilepsy Behav Rep 2021; 16:100494. [PMID: 34877515 PMCID: PMC8627961 DOI: 10.1016/j.ebr.2021.100494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022] Open
Abstract
Evidence-based guidelines use systematic reviews to support clinical recommendations. Adherence to evidence-based guidelines improves healthcare costs and patient outcomes. Recent randomized trials make guidelines for functional neurological disorders possible.
Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.
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Affiliation(s)
- Benjamin Tolchin
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System Center for Clinical Ethics, New Haven, CT, USA
- Corresponding author at: Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, 15 York Street, New Haven, CT 06510, USA.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Barbara A. Dworetzky
- Department of Neurology, The Edward B. Bromfield Epilepsy Center, Brigham and Women’s Hospital, Harvard Medical School., Boston, MA, USA
| | - Laura H. Goldstein
- King’s College London, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - W. Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Steve Martino
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Psychology, VA Connecticut Health Care System, West Haven, CT, USA
| | - David L. Perez
- Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jerzy P. Szaflarski
- UAB Epilepsy Center, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Milligan T, Yun A, Jr LW, Baslet G, Tolchin B, Szaflarski J, Wong V, Plioplys S, Dworetzky B. Neurology Residents’ Education in Functional Seizures. Epilepsy Behav Rep 2021; 18:100517. [PMID: 35243288 PMCID: PMC8857462 DOI: 10.1016/j.ebr.2021.100517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/21/2021] [Accepted: 12/10/2021] [Indexed: 10/28/2022] Open
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13
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Gonsalvez I, Spagnolo P, Dworetzky B, Baslet G. Neurostimulation for the treatment of functional neurological disorder: A systematic review. Epilepsy Behav Rep 2021; 16:100501. [PMID: 34950864 PMCID: PMC8671519 DOI: 10.1016/j.ebr.2021.100501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/28/2021] [Accepted: 11/04/2021] [Indexed: 01/02/2023] Open
Abstract
Functional Neurological Disorder (FND), also known as conversion disorder, is characterized by neurological symptoms that are incompatible with any known structural disorder and best explained by a biopsychosocial model. Evidence-based treatments for FND are limited, with cognitive behavioral therapy (CBT) and physiotherapy being the most effective interventions [1]. In recent years, functional neuroimaging studies have provided robust evidence of alterations in activity and connectivity in multiple brain networks in FND. This body of evidence suggests that neurocircuitry-based interventions, such as non-invasive brain stimulation techniques (NIBS), may also represent an effective therapeutic option for patients with FND. In this systematic review, we outline the current state of knowledge of NIBS in FND, and discuss limitations and future directions that may help establish the efficacy of NIBS as a therapeutic option for FND.
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Affiliation(s)
- Irene Gonsalvez
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Primavera Spagnolo
- Mary Horrigan Connors Center for Women's Health & Gender Biology, Department of Psychiatry, Brigham and Women Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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14
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Wardrope A, Dworetzky BA, Barkley GL, Baslet G, Buchhalter J, Doss J, Goldstein LH, Hallett M, Kozlowska K, LaFrance WC, McGonigal A, Mildon B, Oto M, Perez DL, Riker E, Roberts NA, Stone J, Tolchin B, Reuber M. How to do things with words Two seminars on the naming of functional (psychogenic, non-epileptic, dissociative, conversion, …) seizures. Seizure 2021; 93:102-110. [PMID: 34740139 DOI: 10.1016/j.seizure.2021.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022] Open
Abstract
Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysms of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite this importance, there remains little agreement - and frequent debate - on what to call this condition, known inter alia as psychogenic non-epileptic seizures (PNES), dissociative seizures (DS), functional seizures (FS), non-epileptic attack disorder (NEAD), pseudoseizures, conversion disorder with seizures, and by many other labels besides. This choice of terminology is not merely academic - it affects patients' response to and understanding of their diagnosis, and their ability to navigate health care systems.This paper summarises two recent discussions hosted by the American Epilepsy Society and Functional Neurological Disorders Society on the naming of this condition. These discussions are conceptualised as the initial step of an exploration of whether it might be possible to build consensus for a new diagnostic label.
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Affiliation(s)
- Alistair Wardrope
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom; Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.
| | - Barbara A Dworetzky
- The Edward B. Bromfield Epilepsy Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gregory L Barkley
- Department of Neurology, Henry Ford Hospital, Detroit, MI, United States; Department of Neurology, Wayne State University, Detroit, MI, United States
| | - Gaston Baslet
- Center for Brain/Mind Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jeffrey Buchhalter
- Section of Pediatric Neurology, University of Calgary, Calgary, Alberta, Canada
| | - Julia Doss
- Doss Clinic of Health Psychology, Minneapolis, MN, United States; Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States
| | - Laura H Goldstein
- King's College London Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Kasia Kozlowska
- Children's Hospital at Westmead, Westmead, NSW, Australia; Discipline of Psychiatry and Discipline of Child & Adolescent Health, University of Sydney Medical School, Sydney, Australia; Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - W Curt LaFrance
- Alpert Medical School, Brown University, Providence, RI, United States; Department of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, RI, United States
| | - Aileen McGonigal
- Aix Marseille Univ, Inserm, INS, Institut de Neurosciences des Systèmes, Marseille, France; APHM, Timone Hospital, Clinical Neurophysiology, Marseille, France
| | | | - Maria Oto
- Scottish Epilepsy Centre, Glasgow, United Kingdom
| | - David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ellen Riker
- National Association of Epilepsy Centers, Washington, DC, United States
| | - Nicole A Roberts
- School of Social and Behavioural Sciences, Arizona State University, Phoenix, AZ, United States
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Benjamin Tolchin
- Yale New Haven Health System Center for Bioethics, Yale School of Medicine, New Haven, CT, United States
| | - Markus Reuber
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom; Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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)
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Myers L, Sarudiansky M, Korman G, Baslet G. Using evidence-based psychotherapy to tailor treatment for patients with functional neurological disorders. Epilepsy Behav Rep 2021; 16:100478. [PMID: 34693243 PMCID: PMC8515382 DOI: 10.1016/j.ebr.2021.100478] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Lorna Myers
- Northeast Regional Epilepsy Group, United States
| | - Mercedes Sarudiansky
- National Council for Scientific and Technical Research (CONICET), Institute of Research in Psychology, Faculty of Psychology, University of Buenos Aires, Argentina
| | - Guido Korman
- National Council for Scientific and Technical Research (CONICET), Institute of Research in Psychology, Faculty of Psychology, University of Buenos Aires, Argentina
| | - Gaston Baslet
- Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
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Tolchin B, Baslet G, Martino S, Suzuki J, Blumenfeld H, Hirsch LJ, Altalib H, Dworetzky BA. Motivational Interviewing Techniques to Improve Psychotherapy Adherence and Outcomes for Patients With Psychogenic Nonepileptic Seizures. J Neuropsychiatry Clin Neurosci 2020; 32:125-131. [PMID: 31466516 DOI: 10.1176/appi.neuropsych.19020045] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) are a highly disabling disorder frequently encountered by neurologists, psychiatrists, and emergency medicine physicians. There is accumulating evidence for the efficacy of psychological therapies, yet the majority of patients do not complete treatment. A range of health care system-based, clinician-based, and patient-based barriers to treatment exists, including stigma, poor clinician-patient communication, and patient ambivalence about the diagnosis and treatment of PNES. These barriers frequently lead to treatment nonadherence. Motivational interviewing (MI) is a patient-centered counseling style targeting ambivalence about behavior change, which has been shown to be effective in improving psychotherapy adherence and outcomes among patients with PNES. The authors review MI processes and techniques that may be useful to health care providers helping patients with PNES and other functional neurological disorders to engage in psychotherapy. The authors examine common challenges arising during MI for patients with PNES, including somatic symptoms distracting from clinician-patient communication, ambivalence about making concrete plans for treatment, and psychiatric comorbidities. Strategies for overcoming these obstacles are reviewed, including the use of complex reflections to enhance patient engagement; the use of an ask-tell-ask format and specific, measurable, achievable, relevant, and time-limited (SMART) goals to facilitate treatment planning; and close collaboration between the neurology and psychotherapy teams.
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Affiliation(s)
- Benjamin Tolchin
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Gaston Baslet
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Steve Martino
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Joji Suzuki
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Hal Blumenfeld
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Lawrence J Hirsch
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Hamada Altalib
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
| | - Barbara A Dworetzky
- The Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Conn. (Tolchin, Blumenfeld, Hirsch, Altalib); Neurology Service, Epilepsy Center of Excellence, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Conn. (Tolchin, Altalib); the Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston (Tolchin, Dworetzky); the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet, Suzuki); the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn. (Martino); and Psychology Service, VA Connecticut Healthcare System, West Haven, Conn. (Martino)
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18
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Tolchin B, Perez DL, Szaflarski JP, Baslet G, Doss J, Buchhalter J, Sawchuk T, Dworetzky BA. What's in a name? Epilepsy Behav 2020; 112:107364. [PMID: 32843303 DOI: 10.1016/j.yebeh.2020.107364] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Benjamin Tolchin
- Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA; Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System, West Haven, CT, USA.
| | - David L Perez
- Cognitive Behavioral Neurology and Neuropsychiatry Units, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jerzy P Szaflarski
- Department of Neurology and the UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Julia Doss
- Department of Psychology, Minnesota Epilepsy Group, St. Paul, MN, USA.
| | - Jeffrey Buchhalter
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Tyson Sawchuk
- Comprehensive Children's Epilepsy Center, Alberta Children's Hospital, Calgary, Alberta, Canada.
| | - Barbara A Dworetzky
- Department of Neurology, The Edward B. Bromfield Epilepsy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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19
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Nicholson TR, Carson A, Edwards MJ, Goldstein LH, Hallett M, Mildon B, Nielsen G, Nicholson C, Perez DL, Pick S, Stone J, Aybek S, Baslet G, Bloem BR, Brown RJ, Chalder T, Damianova M, David AS, Epstein S, Espay AJ, Garcin B, Jankovic J, Joyce E, Kanaan RA, Kozlowska K, LaFaver K, LaFrance WC, Lang AE, Lehn A, Lidstone S, Maurer C, Morgante F, Myers L, Reuber M, Rommelfanger K, Schwingenshuh P, Serranova T, Shotbolt P, Stebbins G, Tijssen MAJ, Tinazzi M. Outcome Measures for Functional Neurological Disorder: A Review of the Theoretical Complexities. J Neuropsychiatry Clin Neurosci 2020; 32:33-42. [PMID: 31865871 DOI: 10.1176/appi.neuropsych.19060128] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.
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Affiliation(s)
- Timothy R Nicholson
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Alan Carson
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Mark J Edwards
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Laura H Goldstein
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Mark Hallett
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Bridget Mildon
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Glenn Nielsen
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Clare Nicholson
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - David L Perez
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Susannah Pick
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Jon Stone
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
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- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
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Asadi‐Pooya AA, Nicholson TR, Pick S, Baslet G, Benbadis SR, Beghi M, Brigo F, Buchhalter J, D'Alessio L, Dworetzky B, Gigineishvili D, Kanaan RA, Kozlowska K, LaFrance WC, Lehn A, Perez DL, Popkirov S, Pretorius C, Szaflarski JP, Tolchin B, Valente K, Stone J, Reuber M. Driving a motor vehicle and psychogenic nonepileptic seizures: ILAE Report by the Task Force on Psychogenic Nonepileptic Seizures. Epilepsia Open 2020; 5:371-385. [PMID: 32913946 PMCID: PMC7469780 DOI: 10.1002/epi4.12408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/12/2020] [Accepted: 05/16/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about "driving and psychogenic nonepileptic seizures (PNES)"; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive. METHODS Phase 1: Systematic literature review. Phase 2: Collection of international expert opinion using SurveyMonkey®. Experts included the members of the ILAE PNES Task Force and individuals with relevant publications since 2000. Phase 3: Joint analysis of the findings and refinement of conclusions by all participants using email. As an ILAE Report, the resulting text was reviewed by the Psychiatry Commission, the ILAE Task Force on Driving Guidelines, and Executive Committee. RESULTS Eight studies identified by the systematic review process failed to provide a firm evidence base for PNES-related driving regulations, but suggest that most health professionals think restrictions are appropriate. Twenty-six experts responded to the survey. Most held the view that decisions about driving privileges should consider individual patient and PNES characteristics and take account of whether permits are sought for private or commercial driving. Most felt that those with active PNES should not be allowed to drive unless certain criteria were met and that PNES should be thought of as "active" if the last psychogenic seizure had occurred within 6 months. SIGNIFICANCE Recommendations on whether PwPNES can drive should be made at the individual patient level. Until future research has determined the risk of accidents in PwPNES a proposed algorithm may guide decisions about driving advice.
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Affiliation(s)
- Ali A. Asadi‐Pooya
- Epilepsy Research CenterShiraz University of Medical SciencesShirazIran
- Department of NeurologyJefferson Comprehensive Epilepsy CenterThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Timothy R. Nicholson
- Section of Cognitive NeuropsychiatryInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Susannah Pick
- Section of Cognitive NeuropsychiatryInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Gaston Baslet
- Department of PsychiatryBrigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | - Selim R. Benbadis
- Comprehensive Epilepsy ProgramUniversity of South Florida and Tampa General HospitalTampaFLUSA
| | | | | | | | - Luciana D'Alessio
- Epilepsy Center Ramos Mejía y el Cruce HospitalsBuenos Aires UniversityCONICETBuenos AiresArgentina
| | - Barbara Dworetzky
- Department of NeurologyThe Bromfield Epilepsy CenterBrigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | - David Gigineishvili
- Department of Neurology & NeurosurgeryTbilisi State UniversityTbilisiGeorgia
| | - Richard A. Kanaan
- Department of PsychiatryUniversity of MelbourneAustin HealthHeidelbergAustralia
| | - Kasia Kozlowska
- The Children's Hospital at WestmeadWestmead Institute of Medical ResearchUniversity of Sydney Medical SchoolSydneyNSWAustralia
| | | | | | - David L. Perez
- Functional Neurology Research GroupDepartments of Neurology and PsychiatryMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Stoyan Popkirov
- Department of NeurologyUniversity Hospital Knappschaftskrankenhaus BochumRuhr University BochumBochumGermany
| | - Chrisma Pretorius
- Department of PsychologyStellenbosch UniversityStellenboschSouth Africa
| | - Jerzy P. Szaflarski
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamALUSA
| | - Benjamin Tolchin
- Department of NeurologyYale Comprehensive Epilepsy CenterYale School of MedicineNew HavenCTUSA
| | - Kette Valente
- Laboratory of Clinical NeurophysiologyDepartment of PsychiatryUniversity of Sao PauloSao PauloBrazil
| | - Jon Stone
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Markus Reuber
- Academic Department of NeurosciencesUniversity of SheffieldRoyal Hallamshire HospitalSheffieldUK
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21
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Pick S, Anderson DG, Asadi-Pooya AA, Aybek S, Baslet G, Bloem BR, Bradley-Westguard A, Brown RJ, Carson AJ, Chalder T, Damianova M, David AS, Edwards MJ, Epstein SA, Espay AJ, Garcin B, Goldstein LH, Hallett M, Jankovic J, Joyce EM, Kanaan RA, Keynejad RC, Kozlowska K, LaFaver K, LaFrance WC, Lang AE, Lehn A, Lidstone S, Maurer CW, Mildon B, Morgante F, Myers L, Nicholson C, Nielsen G, Perez DL, Popkirov S, Reuber M, Rommelfanger KS, Schwingenshuh P, Serranova T, Shotbolt P, Stebbins GT, Stone J, Tijssen MA, Tinazzi M, Nicholson TR. Outcome measurement in functional neurological disorder: a systematic review and recommendations. J Neurol Neurosurg Psychiatry 2020; 91:638-649. [PMID: 32111637 PMCID: PMC7279198 DOI: 10.1136/jnnp-2019-322180] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/10/2019] [Accepted: 12/20/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes. METHODS A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group. RESULTS Five FND-specific measures were identified-three clinician-rated and two patient-rated-but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost-utility (eg, healthcare resource use and quality-adjusted life years). CONCLUSIONS There are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population.
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Affiliation(s)
- Susannah Pick
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David G Anderson
- Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran, Islamic Republic of.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Selma Aybek
- Department of Neurology, University Hospital Bern & University of Bern, Bern, Switzerland
| | - Gaston Baslet
- Department of Psychiatry, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | | | - Richard J Brown
- School of Health Sciences, The University of Manchester, Manchester, UK
| | - Alan J Carson
- Department of Clinical Neurosciences, School of Molecular and Clinical Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Trudie Chalder
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maria Damianova
- Donald Gordon Medical Centre, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthony S David
- Institute of Mental Health, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Mark J Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University, London, UK
| | - Steven A Epstein
- Department of Psychiatry, Georgetown University, Washington, District of Columbia, USA
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Béatrice Garcin
- Department of Neurology, Hopital Avicenne, Assistance Publique, Hôpitaux de Paris, Paris, Île-de-France, France
| | - Laura H Goldstein
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Eileen M Joyce
- University College London Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Richard A Kanaan
- Department of Psychiatry, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Roxanne C Keynejad
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Kasia Kozlowska
- Discipline of Psychiatry and Child and Adolescent Health, The Children's Hospital at Westmead, Sydney Medical School, Sydney, New South Wales, Australia
| | - Kathrin LaFaver
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - W Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown Medical School, Providence, RI, USA
| | - Anthony E Lang
- Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Ontario, Canada
| | - Alex Lehn
- Mater Neurosciences Centre, Brisbane, Queensland, Australia
| | - Sarah Lidstone
- Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, University Health Network, Toronto, Ontario, Canada
| | - Carine W Maurer
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | | | - Francesca Morgante
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University, London, UK
| | - Lorna Myers
- Northeast Regional Epilepsy Group, New York, New York, USA
| | - Clare Nicholson
- Therapy Services, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Glenn Nielsen
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University, London, UK
| | - David L Perez
- Departments of Neurology and Psychiatry, Therapy Services, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Karen S Rommelfanger
- Departments of Neurology and Psychiatry and Behavioral Sciences, Emory Centre for Ethics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Tereza Serranova
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, Prague, Czech Republic
| | - Paul Shotbolt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Glenn T Stebbins
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jon Stone
- Department of Clinical Neurosciences, School of Molecular and Clinical Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Marina Aj Tijssen
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michele Tinazzi
- Department of Neuroscience, Biomedicine, and Movement, University of Verona, Verona, Italy
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Baslet G, Ehlert A, Oser M, Dworetzky BA. Mindfulness-based therapy for psychogenic nonepileptic seizures. Epilepsy Behav 2020; 103:106534. [PMID: 31680023 DOI: 10.1016/j.yebeh.2019.106534] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mindfulness-based therapies (MBTs) are effective in many neuropsychiatric disorders, and represent a potential therapeutic strategy for psychogenic nonepileptic seizures (PNES). OBJECTIVE The objective of this study was to investigate the clinical effect of a manualized 12-session MBT for PNES in an uncontrolled trial. We hypothesized reductions in PNES frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion. METHODS Between August 2014 and February 2018, 49 patients with documented PNES (with video electroencephalography [EEG]) were recruited at Brigham and Women's Hospital to participate in the MBT for PNES treatment study. Baseline demographic and clinical information and self-rating scales were obtained during the diagnostic evaluation (T0). Baseline PNES frequency, intensity, and duration were collected at the first follow-up postdiagnosis (T1). Frequency was obtained at each subsequent MBT session and analyzed over time with median regression analysis. Outcomes for other measures were collected at the last MBT session (T3), and compared to baseline measures using linear mixed models. RESULTS Twenty-six patients completed the 12-session MBT program and were included in the analysis. Median PNES frequency decreased by 0.12 events/week on average with each successive MBT session (p = 0.002). At session 12, 70% of participants endorsed a reduction in PNES frequency of at least 50%. Freedom from PNES was reported by 50% of participants by treatment conclusion. Seventy percent reported a 50% reduction in frequency from baseline and 50% reported remission at session 12. By treatment end, PNES intensity decreased (p = 0.012) and quality of life improved (p = 0.002). Event duration and psychiatric symptom severity were lower after treatment, but reductions were not statistically significant. CONCLUSIONS Completion of a manualized 12-session MBT for PNES provides improvement in PNES frequency, intensity, and quality of life. The high dropout rate is consistent with adherence studies in PNES. Possible reasons for dropout are discussed. Randomized controlled trials and longer-term outcomes are needed to demonstrate the efficacy of MBT in PNES.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Alexa Ehlert
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
| | - Megan Oser
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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Rosales R, Dworetzky B, Baslet G. Cognitive-emotion processing in psychogenic nonepileptic seizures. Epilepsy Behav 2020; 102:106639. [PMID: 31731107 DOI: 10.1016/j.yebeh.2019.106639] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Previous literature suggests that cognitive-emotion processing contributes to the pathogenesis of psychogenic nonepileptic seizures (PNES). Characterization of alterations in cognitive-emotion processing in PNES could inform treatment. METHODS In this descriptive, cross-sectional study, 143 patients with video electroencephalogram (EEG) confirmed PNES were prospectively recruited. Patients completed self-report questionnaires on emotion perception (Trait Meta-Mood Scale (TMMS) attention and clarity subscales) and coping style (Affective Styles Questionnaire [ASQ] concealing, adjusting, and tolerating subscales) at the time of their initial evaluation for PNES. Demographic, clinical data and measures of psychopathology severity were also obtained. The TMMS and ASQ subscale scores were compared to available normative data and between PNES subgroups (based on presence of trauma-related factors). Correlation coefficients were obtained to evaluate associations between subscale scores and measures of psychopathology. RESULTS Mean scores on both TMMS subscales (attention 47.0 [SD 7.4] and clarity 37.5 [SD 8.0]) and the ASQ adjusting subscale (22.2 [SD 6.3]) were significantly lower than available normative data (p < .001). Among patients with PNES, those with a history of childhood abuse or active posttraumatic stress disorder (PTSD) were found to have significantly lower scores on emotion clarity, adjustment, and tolerance subscales than those without such histories (p < .05). Degree of clarity of emotions correlated negatively with severity of depression, anxiety, stress, and illness perception (p ≤ .001). Adjustment to and tolerance of emotional states correlated negatively with severity of depression and stress (p < .01). CONCLUSIONS Patients with PNES, especially those with active PTSD and childhood trauma, have lower clarity of their emotions and lower ability to adjust to emotional states than healthy individuals. These cognitive-emotion processing deficits are more pronounced in patients with more severe depression and reported stress. This study characterizes alterations in cognitive-emotion processing in PNES that are well-suited therapeutic targets and can therefore inform treatment interventions.
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Affiliation(s)
- Rachael Rosales
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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Tolchin B, Dworetzky BA, Martino S, Blumenfeld H, Hirsch LJ, Baslet G. Author response: Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures. Neurology 2019; 93:981. [DOI: 10.1212/wnl.0000000000008560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Tolchin B, Baslet G, Suzuki J, Martino S, Blumenfeld H, Hirsch LJ, Altalib H, Dworetzky BA. Randomized controlled trial of motivational interviewing for psychogenic nonepileptic seizures. Epilepsia 2019; 60:986-995. [DOI: 10.1111/epi.14728] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Benjamin Tolchin
- Department of NeurologyComprehensive Epilepsy CenterYale University School of Medicine New Haven Connecticut
- Epilepsy Center of Excellence, Neurology ServiceVeterans Administration Connecticut Healthcare System West Haven Connecticut
- Department of NeurologyBrigham and Women's HospitalHarvard Medical School Boston Massachusetts
| | - Gaston Baslet
- Department of PsychiatryBrigham and Women's HospitalHarvard Medical School Boston Massachusetts
| | - Joji Suzuki
- Department of PsychiatryBrigham and Women's HospitalHarvard Medical School Boston Massachusetts
| | - Steve Martino
- Department of PsychiatryYale University School of Medicine New Haven Connecticut
- Psychology ServiceVeterans Administration Connecticut Healthcare System West Haven Connecticut
| | - Hal Blumenfeld
- Department of NeurologyComprehensive Epilepsy CenterYale University School of Medicine New Haven Connecticut
| | - Lawrence J. Hirsch
- Department of NeurologyComprehensive Epilepsy CenterYale University School of Medicine New Haven Connecticut
| | - Hamada Altalib
- Department of NeurologyComprehensive Epilepsy CenterYale University School of Medicine New Haven Connecticut
- Epilepsy Center of Excellence, Neurology ServiceVeterans Administration Connecticut Healthcare System West Haven Connecticut
- Department of PsychiatryYale University School of Medicine New Haven Connecticut
| | - Barbara A. Dworetzky
- Department of NeurologyBrigham and Women's HospitalHarvard Medical School Boston Massachusetts
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Latreille V, Dworetzky BA, Baslet G, Pavlova M. Sleep disturbances in patients with psychogenic non-epileptic seizures: Is it all subjective? A prospective pilot study of sleep-wake patterns. Seizure 2019; 65:124-128. [PMID: 30685518 DOI: 10.1016/j.seizure.2019.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Patients with psychogenic non-epileptic seizures (PNES) frequently complain of poor sleep, yet there are few and inconsistent data supporting objective sleep disturbances in this population. In this prospective observational study, we aimed to compare objective and subjective sleep-wake patterns in patients with PNES with those with epilepsy. METHODS Subjects were recruited through the Brigham and Women's Epilepsy Monitoring Unit (EMU) over a 6-month period, and were diagnosed as having PNES or epilepsy by experts using video-electroencephalography (v-EEG). Sleep-wake patterns were objectively examined using EEG and actigraphy during EMU admission. Subjects also completed several validated questionnaires on sleep. RESULTS Twenty-seven subjects, including 17 with PNES and 10 with epilepsy were enrolled in the study. Compared to controls with epilepsy, PNES subjects showed greater sleep onset latency (48.7 ± 47.5 min vs 14.0 ± 13.4 min; p = 0.02). Otherwise, sleep architecture was similar between the groups. However, subjectively, PNES subjects reported worse sleep quality (10.8 ± 5.1 vs 5.8 ± 2.9; p = 0.01) and were more likely to meet clinical criteria for insomnia relative to epilepsy subjects (50% vs 10%, p = 0.05). Moreover, a higher proportion of PNES subjects reported taking medications for sleep (44% vs 0%, p = 0.01). CONCLUSION Overall, we found more evidence for a subjective basis rather than a pathophysiological nature for the reported sleep disturbances in PNES subjects. In addition to educating PNES patients on the importance of maintaining good sleep habits, clinicians should address sleep complaints and screen for insomnia, as effective treatments are available and may improve overall health.
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Affiliation(s)
- Véronique Latreille
- Brigham and Women's Hospital, Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Barbara A Dworetzky
- Brigham and Women's Hospital, Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Gaston Baslet
- Brigham and Women's Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Milena Pavlova
- Brigham and Women's Hospital, Department of Neurology, Harvard Medical School, Boston, MA, USA.
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Tolchin B, Dworetzky BA, Martino S, Blumenfeld H, Hirsch LJ, Baslet G. Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures. Neurology 2019; 92:e675-e679. [PMID: 30610097 DOI: 10.1212/wnl.0000000000006848] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 10/11/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We conducted a prospective cohort study of patients with psychogenic nonepileptic seizures (PNES) to examine the association between adherence with psychotherapy and outcomes, including significant (≥50%) reduction in PNES frequency, PNES freedom, improvement in quality of life, and reduction in emergency department (ED) utilization. METHODS A total of 105 participants were referred to receive psychotherapy either at Brigham and Women's Hospital or with a local therapist. We called participants at 12-24 months follow-up and obtained detailed follow-up data from 93 participants (89%). Participants were considered adherent with psychotherapy if they attended at least 8 sessions within a 16-week period starting at the time of referral. RESULTS Adherence with psychotherapy was associated with reduction in seizure frequency (84% in adherent group vs 61% in nonadherent, p = 0.021), improvement in quality of life (p = 0.044), and reduction in ED utilization (p = 0.040), with medium effect sizes; there was no difference in PNES freedom. The association between adherence and ≥50% reduction in PNES frequency persisted when controlling for potential confounders in a multivariate model. Psychotherapy nonadherence was associated with baseline characteristics of self-identified minority status (odds ratio 7.47, p = 0.019) and history of childhood abuse (odds ratio 3.30, p = 0.023). CONCLUSIONS Our study is limited in that it cannot establish a causal relationship between adherence with psychotherapy and outcomes, and the results may not generalize beyond the single quaternary care center study site. Among participants with documented PNES, adherence with psychotherapy was associated with reduction in PNES frequency, improvement in quality of life, and decrease in ED visits.
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Affiliation(s)
- Benjamin Tolchin
- From the Comprehensive Epilepsy Center, Department of Neurology (B.T., H.B., L.J.H.), and Department of Psychiatry (S.M.), Yale University School of Medicine, New Haven, CT; Epilepsy Center of Excellence, Neurology Service (B.T.), and Psychology Service (S.M.), VA Connecticut Healthcare System, Newington; and Departments of Neurology (B.T., B.A.D.) and Psychiatry (G.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Barbara A Dworetzky
- From the Comprehensive Epilepsy Center, Department of Neurology (B.T., H.B., L.J.H.), and Department of Psychiatry (S.M.), Yale University School of Medicine, New Haven, CT; Epilepsy Center of Excellence, Neurology Service (B.T.), and Psychology Service (S.M.), VA Connecticut Healthcare System, Newington; and Departments of Neurology (B.T., B.A.D.) and Psychiatry (G.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steve Martino
- From the Comprehensive Epilepsy Center, Department of Neurology (B.T., H.B., L.J.H.), and Department of Psychiatry (S.M.), Yale University School of Medicine, New Haven, CT; Epilepsy Center of Excellence, Neurology Service (B.T.), and Psychology Service (S.M.), VA Connecticut Healthcare System, Newington; and Departments of Neurology (B.T., B.A.D.) and Psychiatry (G.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hal Blumenfeld
- From the Comprehensive Epilepsy Center, Department of Neurology (B.T., H.B., L.J.H.), and Department of Psychiatry (S.M.), Yale University School of Medicine, New Haven, CT; Epilepsy Center of Excellence, Neurology Service (B.T.), and Psychology Service (S.M.), VA Connecticut Healthcare System, Newington; and Departments of Neurology (B.T., B.A.D.) and Psychiatry (G.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence J Hirsch
- From the Comprehensive Epilepsy Center, Department of Neurology (B.T., H.B., L.J.H.), and Department of Psychiatry (S.M.), Yale University School of Medicine, New Haven, CT; Epilepsy Center of Excellence, Neurology Service (B.T.), and Psychology Service (S.M.), VA Connecticut Healthcare System, Newington; and Departments of Neurology (B.T., B.A.D.) and Psychiatry (G.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gaston Baslet
- From the Comprehensive Epilepsy Center, Department of Neurology (B.T., H.B., L.J.H.), and Department of Psychiatry (S.M.), Yale University School of Medicine, New Haven, CT; Epilepsy Center of Excellence, Neurology Service (B.T.), and Psychology Service (S.M.), VA Connecticut Healthcare System, Newington; and Departments of Neurology (B.T., B.A.D.) and Psychiatry (G.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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28
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Latreille V, Baslet G, Sarkis R, Pavlova M, Dworetzky BA. Sleep in psychogenic nonepileptic seizures: Time to raise a red flag. Epilepsy Behav 2018; 86:6-8. [PMID: 30032094 DOI: 10.1016/j.yebeh.2018.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
Poor sleep is a frequent complaint in patients with psychogenic nonepileptic seizures (PNES). However, few studies have examined sleep problems in this population. We aimed to compare sleep complaints in patients with PNES with those with epilepsy. Subjects diagnosed as having PNES by experts using video-electroencephalography (vEEG) were recruited through the Brigham and Women's Hospital epilepsy monitoring unit (EMU) between 3/25/2013 and 3/29/2018. Controls were patients with epilepsy recruited through the EMU and subspecialty clinics. All subjects were given the Beck Depression Inventory, 2nd Edition (BDI-II) and the Quality of Life in Epilepsy Inventory-10 (QOLIE-10). Subjective sleep problems were identified from item 16 (changes in sleep patterns) of the BDI-II. Independent sample t-test, chi-square test, and Spearman correlation were used. A total of 149 patients with PNES and 82 patients with epilepsy completed the BDI-II and QOLIE-10. Compared with control subjects with epilepsy, patients with PNES more frequently reported moderate-severe changes in sleep patterns, notably sleeping less than usual, waking up 1-2 h too early, and having trouble returning to sleep. These changes in sleep patterns were associated with worse quality of life. Our findings suggest that sleep is more commonly reported as a problem in PNES compared with epilepsy. Because sleep plays a major role in good health, understanding the specific sleep problem in PNES may provide insight for improving quality of life for this challenging disorder.
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Affiliation(s)
- Veronique Latreille
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America.
| | - Gaston Baslet
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America.
| | - Rani Sarkis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America.
| | - Milena Pavlova
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America.
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States of America.
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Affiliation(s)
- Mary A O'Neal
- From the Departments of Neurology and Psychiatry, Brigham and Women's Hospital, Boston
| | - Gaston Baslet
- From the Departments of Neurology and Psychiatry, Brigham and Women's Hospital, Boston
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Abstract
AbstractPsychogenic nonepileptic seizures (PNES) are the most common type of functional neurological symptom disorders and are frequently diagnosed in tertiary care epilepsy monitoring units. These are associated with significant decline in social functioning and quality of life. The majority of patients with PNES are women, outnumbering men by a ratio of 3:1. Female sex preponderance occurs after puberty and usually before the age of 55 years. Many of the psychiatric risk factors in PNES (depression, anxiety, history of traumatic experiences, other somatic symptom disorders) are more common in women and may partially account for the difference in sex prevalence. Neurobiological and neurohumoral mechanisms may also play a role, but our understanding is limited at this point. In this review, we present information on epidemiology and risk factors, neurobiological and psychological mechanisms, clinical approach to diagnosis, evidence-based treatment, and long-term outcomes. We highlight findings related to differences between women and men in PNES. Most of these data are not decisive and require further corroboration. While the disorder may be more frequently suspected in women, all patients with suspected PNES deserve an objective and thorough investigation of their symptoms. Early and accurate identification of this disorder should be a priority, especially as evidence-based treatments, which may lead to improved outcomes, are increasingly available.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barbara Dworetzky
- Division of Epilepsy, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Tolchin B, Dworetzky BA, Baslet G. Long-term adherence with psychiatric treatment among patients with psychogenic nonepileptic seizures. Epilepsia 2017; 59:e18-e22. [DOI: 10.1111/epi.13969] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Benjamin Tolchin
- Division of Epilepsy; Department of Neurology; Yale New Haven Hospital and VA Connecticut Healthcare System; Yale School of Medicine; New Haven CT USA
| | - Barbara A. Dworetzky
- The Edward B. Bromfield Epilepsy Program; Department of Neurology; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Gaston Baslet
- Department of Psychiatry; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
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Baslet G, Tolchin B, Dworetzky BA. Altered responsiveness in psychogenic nonepileptic seizures and its implication to underlying psychopathology. Seizure 2017; 52:162-168. [PMID: 29049948 DOI: 10.1016/j.seizure.2017.10.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Altered responsiveness during psychogenic nonepileptic seizures (PNES) is a distinct semiological feature that may signal a psychological vulnerability. We hypothesized that altered responsiveness is related to difficulties with emotion tolerance, experiential avoidance, difficulty coping, dissociation and trauma and prior experiences of loss of awareness. METHODS 71 patients with video-EEG confirmed PNES were divided into two groups based on their responsiveness at the time of the captured event during long-term monitoring. Demographic information, clinical history and self-rated questionnaires highlighting psychopathology were compared between the groups. RESULTS 47 patients (66%) had altered responsiveness during their captured event. Married or partnered subjects were more represented in the altered responsiveness group. Experiential avoidance, as measured by the Acceptance and Action Questionnaire-II, and affect intolerance, as measured by the Affective Style Questionnaire, were significantly higher in the altered responsiveness group. The Connor Davidson Resilience Scale was significantly higher among intact responsiveness subjects. Subjects with altered responsiveness were more likely to have a family history of seizures, comorbid headaches, and loss of consciousness (LOC) during traumatic brain injury. There were no differences in measures of dissociation, somatization, mood or anxiety, or presence of psychiatric comorbidities, including PTSD or history of trauma. CONCLUSION Altered responsiveness during PNES is a marker of lower emotional resilience or ability to tolerate emotions among patients with PNES. Emotion management may be an important therapeutic target for these patients. Prior experiences with LOC also contribute to the presence of altered responsiveness. Trauma and dissociation did not differentiate responsiveness during PNES.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, USA.
| | - Benjamin Tolchin
- Department of Neurology, Yale University School of Medicine, 15 York Street, New Haven, CT, USA
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, USA
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Affiliation(s)
- Benjamin Tolchin
- Department of Neurology, Brigham and Women's Hospital - Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital - Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women's Hospital - Harvard Medical School, 75 Francis Street, Boston, MA 02115, United States
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Fischer DB, Perez DL, Prasad S, Rigolo L, O'Donnell L, Acar D, Meadows ME, Baslet G, Boes AD, Golby AJ, Dworetzky BA. Right inferior longitudinal fasciculus lesions disrupt visual-emotional integration. Soc Cogn Affect Neurosci 2016; 11:945-51. [PMID: 26940563 DOI: 10.1093/scan/nsw011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 01/28/2016] [Indexed: 11/14/2022] Open
Abstract
The mechanism by which the brain integrates visual and emotional information remains incompletely understood, and can be studied through focal lesions that selectively disrupt this process. To date, three reported cases of visual hypoemotionality, a vision-specific form of derealization, have resulted from lesions of the temporo-occipital junction. We present a fourth case of this rare phenomenon, and investigate the role of the inferior longitudinal fasciculus (ILF) in the underlying pathophysiology. A 50-year-old right-handed male was found to have a right medial temporal lobe tumor following new-onset seizures. Interstitial laser ablation of the lesion was complicated by a right temporo-parieto-occipital intraparenchymal hemorrhage. The patient subsequently experienced emotional estrangement from visual stimuli. A lesion overlap analysis was conducted to assess involvement of the ILF by this patient's lesion and those of the three previously described cases, and diffusion tensor imaging was acquired in our case to further investigate ILF disruption. All four lesions specifically overlapped with the expected trajectory of the right ILF, and diminished structural integrity of the right ILF was observed in our case. These findings implicate the ILF in visual hypoemotionality, suggesting that the ILF is critical for integrating visual information with its emotional content.
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Affiliation(s)
- David B Fischer
- Harvard Medical School, Boston, MA 02115, USA, Department of Neurology, Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA,
| | - David L Perez
- Department of Neurology and Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA and Department of Psychiatry
| | | | - Laura Rigolo
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Lauren O'Donnell
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | - Aaron D Boes
- Department of Neurology, Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA, Department of Neurology and
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Although somatosensory amplification is theorized to serve a critical role in somatization, it remains poorly understood neurobiologically. In this perspective article, convergent visceral-somatic processing is highlighted, and neuroimaging studies in somatoform disorders are reviewed. Neural correlates of cognitive-affective amplifiers are integrated into a neurocircuit framework for somatosensory amplification. The anterior cingulate cortex, insula, amygdala, hippocampal formation, and striatum are some of the identified regions. Clinical symptomatology in a given patient or group may represent dysfunction in one or more of these neurobehavioral nodes. Somatosensory amplification may, in part, develop through stress-mediated aberrant neuroplastic changes and the neuromodulatory effects of inflammation.
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Affiliation(s)
- David L Perez
- From the Dept. of Psychiatry, Brigham and Women's Hospital, Boston, MA (DLP, AJB, DRV, GB, DAS);. Dept. of Neurology, Brigham and Women's Hospital, Boston, MA (DLP); Functional Neuroimaging Laboratory, Brigham and Women's Hospital, Boston, MA (DLP, DRV DAS); Dept. of Psychiatry, Beth Israel Deaconess Medical Center, Boston, MA (DLP); and Harvard Medical School, Boston, MA (DLP, AJB, DRV, GB, DAS)
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Perez DL, Dworetzky BA, Dickerson BC, Leung L, Cohn R, Baslet G, Silbersweig DA. An integrative neurocircuit perspective on psychogenic nonepileptic seizures and functional movement disorders: neural functional unawareness. Clin EEG Neurosci 2015; 46:4-15. [PMID: 25432161 PMCID: PMC4363170 DOI: 10.1177/1550059414555905] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Functional neurological disorder (conversion disorder) is a neurobehavioral condition frequently encountered by neurologists. Psychogenic nonepileptic seizure (PNES) and functional movement disorder (FMD) patients present to epileptologists and movement disorder specialists respectively, yet neurologists lack a neurobiological perspective through which to understand these enigmatic groups. Observational research studies suggest that PNES and FMD may represent variants of similar (or the same) conditions given that both groups exhibit a female predominance, have increased prevalence of mood-anxiety disorders, frequently endorse prior abuse, and share phenotypic characteristics. In this perspective article, neuroimaging studies in PNES and FMD are reviewed, and discussed using studies of emotional dysregulation, dissociation and psychological trauma in the context of motor control. Convergent neuroimaging findings implicate alterations in brain circuits mediating emotional expression, regulation and awareness (anterior cingulate and ventromedial prefrontal cortices, insula, amygdala, vermis), cognitive control and motor inhibition (dorsal anterior cingulate, dorsolateral prefrontal, inferior frontal cortices), self-referential processing and perceptual awareness (posterior parietal cortex, temporoparietal junction), and motor planning and coordination (supplementary motor area, cerebellum). Striatal-thalamic components of prefrontal-parietal networks may also play a role in pathophysiology. Aberrant medial prefrontal and amygdalar neuroplastic changes mediated by chronic stress may facilitate the development of functional neurological symptoms in a subset of patients. Improved biological understanding of PNES and FMD will likely reduce stigma and aid the identification of neuroimaging biomarkers guiding treatment development, selection, and prognosis. Additional research should investigate neurocircuit abnormalities within and across functional neurological disorder subtypes, as well as compare PNES and FMD with mood-anxiety-dissociative disorders.
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Affiliation(s)
- David L Perez
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Lorene Leung
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachel Cohn
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - David A Silbersweig
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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Reinsberger C, Sarkis R, Papadelis C, Doshi C, Perez DL, Baslet G, Loddenkemper T, Dworetzky BA. Autonomic changes in psychogenic nonepileptic seizures: toward a potential diagnostic biomarker? Clin EEG Neurosci 2015; 46:16-25. [PMID: 25780264 DOI: 10.1177/1550059414567739] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Disturbances of the autonomic nervous system (ANS) are common in neuropsychiatric disorders. Disease specific alterations of both sympathetic and parasympathetic activity can be assessed by heart rate variability (HRV), whereas electrodermal activity (EDA) can assess sympathetic activity. In posttraumatic stress disorder (PTSD), parasympathetic HRV parameters are typically decreased and EDA is increased, whereas in major depressive disorder (MDD) and dissociation, both parasympathetic and sympathetic markers are decreased. ANS abnormalities have also been identified in psychogenic nonepileptic seizures (PNES) by using HRV, indicating lower parasympathetic activity at baseline. In addition to reviewing the current literature on ANS abnormalities in PTSD, MDD, and disorders with prominent dissociation, including borderline personality disorder (BPD), this article also presents data from a pilot study on EDA in patients with PNES. Eleven patients with PNES, during an admission to our epilepsy monitoring unit (EMU), were compared with 9 with generalized tonic-clonic seizures (GTCS). The area under the EDA curve, the number of EDA responses lasting longer than 2 seconds, and the number of EDA surges during sleep (sympathetic sleep storms) were calculated on ictal and interictal days by an automated algorithm. EDA changes in PNES patients did not follow a systematic pattern of sympathetic hyperarousal (like EDA after GTCS) but were more variable. How specific PNES semiologies, and/or underlying neuropsychiatric disorders, may influence ictal and interictal EDA patterns, and lead to a novel diagnostic biomarker remains to be evaluated in future larger studies.
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Affiliation(s)
- Claus Reinsberger
- Edward B. Bromfield Epilepsy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Institute of Sports Medicine, University of Paderborn, Paderborn, Germany
| | - Rani Sarkis
- Edward B. Bromfield Epilepsy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christos Papadelis
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chiran Doshi
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David L Perez
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gaston Baslet
- Edward B. Bromfield Epilepsy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara A Dworetzky
- Edward B. Bromfield Epilepsy Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Baslet G, Dworetzky B, Perez DL, Oser M. Treatment of psychogenic nonepileptic seizures: updated review and findings from a mindfulness-based intervention case series. Clin EEG Neurosci 2015; 46:54-64. [PMID: 25465435 PMCID: PMC4552047 DOI: 10.1177/1550059414557025] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) were first described in the medical literature in the 19th century, as seizure-like attacks not related to an identified central nervous system lesion, and are currently classified as a conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). While a universally accepted and unifying etiological model does not yet exist, several risk factors have been identified. Management of PNES should be based on interdisciplinary collaboration, targeting modifiable risk factors. The first treatment phase in PNES is patient engagement, which is challenging given the demonstrated low rates of treatment retention. Acute interventions constitute the next phase in treatment, and most research studies focus on short-term evidence-based interventions. Randomized controlled pilot trials support cognitive-behavioral therapy. Other psychotherapeutic and psychopharmacological interventions have been less well-studied using controlled and uncontrolled trials. Within the discussion of acute interventions, we present a preliminary evaluation for feasibility of a mindfulness-based psychotherapy protocol in a very small sample of PNES patients. We demonstrated in 6 subjects that this intervention is feasible in real-life clinical scenarios and warrants further investigation in larger scale studies. The final treatment phase is long-term follow-up. Long-term outcome studies in PNES show that a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality. We believe that PNES should be understood as a disease that requires different types of intervention during the various phases of treatment.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Barbara Dworetzky
- Harvard Medical School, Boston, MA, USA Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - David L Perez
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Department of Neurology, Massachusetts General Hospital, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Megan Oser
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
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Willment K, Hill M, Baslet G, Loring DW. Cognitive impairment and evaluation in psychogenic nonepileptic seizures: an integrated cognitive-emotional approach. Clin EEG Neurosci 2015; 46:42-53. [PMID: 25780266 DOI: 10.1177/1550059414566881] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neuropsychological studies comparing patients with psychogenic nonepileptic seizures (PNES) to those with epilepsy have been largely equivocal. The variability in the neuropsychological literature highlights the heterogeneity of the PNES population across a number of psychiatric and neurologic factors. Phenotypic presentations in PNES arise from complex interactions between vulnerable cognitive and emotional systems. We propose that variability in neuropsychological findings in PNES emerge in the context of diverse psychiatric, neurologic, and clinical factors. Traditional assessments that fail to integrate cognitive and emotional/behavioral profiles sufficiently would fall short in characterizing the complexity of brain-behavior relationships in this population. To advance the neuropsychology of PNES, we propose a systematic approach to measure a number of factors that influence cognitive impairment in this population. We begin by reviewing the current neuropsychological literature in PNES and discussing a number of factors that influence cognitive deficits. We then present a comprehensive neuropsychological battery designed to capture elements (cognitive dysfunction, psychopathology, emotion processing deficits) underlying the proposed vulnerable cognitive-emotional system in PNES. It is our hope that the proposed battery will facilitate the aggregation of data across neuropsychological investigations, to allow more advanced statistical analyses, and ultimately enhance our understanding of PNES and the development of effective management and treatment options.
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Affiliation(s)
- Kim Willment
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Melanie Hill
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - David W Loring
- Departments of Neurology and Pediatrics, Emory University, Atlanta, GA, USA
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Abstract
Psychogenic nonepileptic seizures (PNES) can present emergently and are often mistaken for epileptic seizures. PNES emergencies have not been well studied, and yet there are associated serious morbidities, particularly when patients are seen in an emergency setting and are misdiagnosed. PNES may be prolonged, mimicking status epilepticus, a condition we refer to as nonepileptic psychogenic status (NEPS), and patients may receive aggressive and unnecessary medical treatments that can lead to serious iatrogenic complications, including death. NEPS is also associated with an increased risk of self-harm, including suicide attempts, and may indicate a serious comorbid psychiatric illness. In addition to iatrogenic complications of PNES, accidents and injuries are an underrecognized source of morbidity. PNES may also present during medical procedures, which may not only interfere with their completion, but may alarm practitioners who, fearing liability, may initiate further medical evaluations and treatments. When PNES occur during pregnancy, patients may be misdiagnosed with eclampsia and their offspring delivered prematurely. They also risk being placed on medications that are harmful to the fetus. Increased awareness of PNES is necessary to prevent iatrogenic harm and to identify underlying psychiatric illnesses that carry their own risks. As yet, data available to guide treatment are scant, and further study is needed.
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Affiliation(s)
- Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel S Weisholtz
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David L Perez
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
This study investigated whether initial adherence to treatment in psychogenic epileptic seizures differed on the basis of mental health treatment modality and which subject characteristics were predictive of adherence. Initial adherence rates were 54% for combined treatment conducted in the same institution (integrated intervention) and 31% for psychotherapy and psychiatric management offered in different settings (divided intervention). Cognitive complaints and current exposure to antiepileptic drugs (AEDs) were more common among nonadherent patients, and being married (or having a live-in partner) was more common among adherent patients. A predictive model using the mentioned variables (intervention type, marital status, cognitive complaints, and concurrent use of AEDs) showed that this set of variables was predictive of adherence. Marital status and cognitive complaints were the significant contributors to prediction of adherence in the model.
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Affiliation(s)
- Gaston Baslet
- Dept. of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA.
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Sarkis RA, Pietras AC, Cheung A, Baslet G, Dworetzky B. Neuropsychological and psychiatric outcomes in poorly controlled idiopathic generalized epilepsy. Epilepsy Behav 2013; 28:370-3. [PMID: 23832134 DOI: 10.1016/j.yebeh.2013.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/14/2013] [Accepted: 05/20/2013] [Indexed: 10/26/2022]
Abstract
The neuropsychological and psychiatric outcomes of patients with poorly controlled idiopathic generalized epilepsy (IGE) have not been well characterized. The current study aimed to compare these outcomes to a group of patients with medically refractory temporal lobe epilepsy (TLE). A retrospective review of patients admitted to the epilepsy monitoring unit identified 19 patients with IGE and 23 patients with TLE who underwent neuropsychological and psychiatric evaluations. Patients with IGE required a longer time to complete the Trail Making Tests and had lower performance IQ compared to patients with TLE. Despite a higher burden of convulsions, patients with IGE had lower depression scores on the Beck Depression Inventory-II (BDI-II) than patients with TLE. In the group with IGE, the BDI-II scores were inversely correlated with epilepsy duration. These findings indicate that patients with IGE have lower performance IQ, impaired performance on tests of executive functioning, and lower depression scores compared to patients with TLE, implicating different pathophysiological processes.
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Affiliation(s)
- Rani A Sarkis
- The Edward B. Bromfield Epilepsy Service, Department of Neurology, Harvard Medical School, MA, USA.
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Abstract
Psychogenic nonepileptic seizures (PNES) can significantly affect an individual's quality of life, the health care system, and even society. The first decade of the new millennium has seen renewed interest in this condition, but etiological understanding and evidence-based treatment availability remain limited. After the diagnosis of PNES is established, the first therapeutic step includes a presentation of the diagnosis that facilitates engagement in treatment. The purpose of this review is to present the current evidence of treatments for PNES published since the year 2000 and to discuss further needs for clinical treatment implementation and research. This article reviews clinical trials that have evaluated the efficacy of structured, standardized psychotherapeutic and psychopharmacological interventions. The primary outcome measure in clinical trials for PNES is event frequency, although it is questionable whether this is the most accurate indicator of functional recovery. Cognitive behavioral therapy has evidence of efficacy, including one pilot randomized, controlled trial where cognitive behavioral therapy was compared with standard medical care. The antidepressant sertraline did not show a significant difference in event frequency change when compared to placebo in a pilot randomized, double-blind, controlled trial, but it did show a significant pre- versus posttreatment decrease in the active arm. Other interventions that have shown efficacy in uncontrolled trials include augmented psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy, group psychoeducation, and the antidepressant venlafaxine. Larger clinical trials of these promising treatments are necessary, while other psychotherapeutic interventions such as hypnotherapy, mindfulness-based therapies, and eye movement desensitization and reprocessing may deserve exploration. Flexible delivery of treatment that considers the heterogeneous backgrounds of patients is emphasized as necessary for successful outcomes in clinical practice.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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45
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Baslet G, Hill J. Case Report: Brief Mindfulness-Based Psychotherapeutic Intervention During Inpatient Hospitalization in a Patient With Conversion and Dissociation. Clin Case Stud 2011. [DOI: 10.1177/1534650110396359] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Conversion and dissociative disorders have psychopathological mechanisms in common and can simultaneously be present in the same patient. Evidence-based treatments for conversion and dissociative disorders are limited and mostly focused on cognitive-behavioral therapies (CBT) for a few conversion disorders. Avoidance and difficulties in emotion expression are thought to explain conversion and hence, mindfulness-based therapies (MBTs) could hypothetically constitute a beneficial intervention. Here, we present the case of Anne, a 31-year-old female with a long-term history of depression, anxiety, and psychogenic nonepileptic seizures (PNES). While facing health-related and marital stressors, Anne acutely developed conversion left-sided paralysis, psychogenic bilateral tremor, and dissociative amnesia and had an increase in PNES frequency. Some of these newly developed symptoms resolved and other improved significantly after an acceptance and commitment therapy (ACT) intervention was offered during a brief inpatient hospitalization. This constitutes the first report of an ACT-based intervention used in this type of clinical syndromes.
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Affiliation(s)
| | - James Hill
- Morita School of Japanese Psychology, Riverside, Illinois, University of Illinois Medical Center, Chicago
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Baslet G. Psychogenic non-epileptic seizures: a model of their pathogenic mechanism. Seizure 2010; 20:1-13. [PMID: 21106406 DOI: 10.1016/j.seizure.2010.10.032] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 09/22/2010] [Accepted: 10/25/2010] [Indexed: 10/18/2022] Open
Abstract
Psychogenic non-epileptic seizures (PNES) consist of paroxystic events facilitated by a dysfunction in emotion processing. Models explaining the pathogenic mechanisms leading to these seizure-like episodes are limited. In this article, evidence that supports dysfunction at the level of arousal tolerance, cognitive-emotional information processing and volitional control is reviewed. A hypothetical pathophysiological mechanism is discussed based on functional neuroimaging evidence from PNES-related conditions and traits. This pathophysiological model suggests an alteration in the influence and connection of brain areas involved in emotion processing onto other brain areas responsible for sensorimotor and cognitive processes. Integrating this information, PNES are conceptualized as brief episodes facilitated by an unstable cognitive-emotional attention system. During the episodes, sensorimotor and cognitive processes are modified or not properly integrated, allowing the deployment of autonomous prewired behavioral tendencies. Finally, I elaborate on how therapeutic applications could be modified based on the proposed hypothetical model, potentially improving clinical outcomes.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, University of Illinois at Chicago, 912 South Wood Street, M/C 913, Chicago, IL 60612, USA.
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Abstract
Cancers of the brain can cause alterations in a person's neurocognitive abilities, and in some patients can even challenge their concept of self and self-identity. Cancer treatment may offer some hope for longer survival, but residual neurocognitive alterations generally remain. Individualized care for these patients should include information related to anticipated effects of their disease or treatments affecting their perception or expression of self. At present, the concepts of self and self-identity are largely unexplored in neuro-oncology, but we will discuss this clinical population in order to highlight the need for further clinical evaluation of these phenomena among patients with brain neoplasm. Finally, we will briefly note the need for a clinical tool to assess self and self-identity changes in brain tumor patients.
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Affiliation(s)
- Lisa Anderson-Shaw
- University of Illinois Medical Center, 1740 W. Taylor, Suite 1440, MC 693, Chicago, IL 60612,
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