title: Changes in Emotion Processing following Brief Augmented Psychodynamic Interpersonal Therapy for Functional Neurological Symptoms. COgnitive behavioural therapy vs standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES): a multicentre randomised controlled trial protocol A standardized diagnostic approach and ongoing feedback improves outcome in psychogenic nonepileptic seizures Somatization Increases Disability Independent of Comorbidity Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. An exploratory randomized controlled trial of immediate versus delayed withdrawal of antiepileptic drugs in patients with psychogenic nonepileptic attacks (PNEAs). Behavior therapy in dissociative convulsions disorder. Fatigue, not self-rated motor symptom severity, affects quality of life in functional motor disorders Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures
abstract: BACKGROUND Functional neurological symptoms ( FNS ) are considered non-volitional and often very disabling , but are not explainable by neurological disease or structural abnormalities . Brief Augmented Psychodynamic Interpersonal Therapy ( BAPIT ) was adapted to treat the putative emotion processing deficits thought to be central to FNS aetiology and maintenance . BAPIT for FNS has previously been shown to improve levels of distress and functioning , but it is unknown whether improvements on such measures correlate with changes in emotion processing ‒ which this treatment focuses on . AIM To determine ( a ) whether the recently developed Emotional Processing Scale-25 can be used to demonstrate BAPIT-associated changes in patients with FNS , and ( b ) whether changes in the EPS-25 are associated with changes in previously vali date d outcome measures . METHOD 44 patients with FNS completed question naires including the EPS-25 and measures of clinical symptomology ( health-related quality of life ( SF-36 ) , somatic symptoms ( PHQ-15 ) , psychological distress ( CORE-10 ) and illness underst and ing ( BIPQ ) ) pre- and post-therapy . RESULTS At group level , emotion processing improved following therapy ( p = .049 ) . Some measures of clinical symptomology also improved , namely health-related quality of life ( p = .02 ) and illness underst and ing ( p = .01 ) . Improvements in the EPS-25 correlated with improvements in mental health-related quality of life and psychological distress . CONCLUSIONS Emotion processing and some measures of clinical symptomology improved in patients with FNS following BAPIT . The EPS-25 demonstrated changes that correlated with previously vali date d outcome measures . The EPS-25 is a suitable measure of psychotherapy-associated change in the FNS patient population Background The evidence base for the effectiveness of psychological interventions for patients with dissociative non-epileptic seizures ( DS ) is currently extremely limited , although data from two small pilot r and omised controlled trials ( RCTs ) , including from our group , suggest that Cognitive Behavioural Therapy ( CBT ) may be effective in reducing DS occurrence and may improve aspects of psychological status and psychosocial functioning . Methods / Design The study is a multicentre , pragmatic parallel group RCT to evaluate the clinical and cost-effectiveness of specifically-tailored CBT plus st and ardised medical care ( SMC ) vs SMC alone in reducing DS frequency and improving psychological and health-related outcomes . In the initial screening phase , patients with DS will receive their diagnosis from a neurologist/epilepsy specialist . If patients are eligible and interested following the provision of study information and a booklet about DS , they will consent to provide demographic information and fortnightly data about their seizures , and agree to see a psychiatrist three months later . We aim to recruit ~500 patients to this screening stage . After a review three months later by a psychiatrist , those patients who have continued to have DS in the previous eight weeks and who meet further eligibility criteria will be told about the trial comparing CBT + SMC vs SMC alone . If they are interested in participating , they will be given a further booklet on DS and study information . A research worker will see them to obtain their informed consent to take part in the RCT . We aim to r and omise 298 people ( 149 to each arm ) . In addition to a baseline assessment , data will be collected at 6 and 12 months post r and omisation . Our primary outcome is monthly seizure frequency in the preceding month . Secondary outcomes include seizure severity , measures of seizure freedom and reduction , psychological distress and psychosocial functioning , quality of life , health service use , cost effectiveness and adverse events . We will include a nested qualitative study to evaluate participants ’ views of the intervention and factors that acted as facilitators and barriers to participation . Discussion This study will be the first adequately powered evaluation of CBT for this patient group and offers the potential to provide an evidence base for treating this patient group . Trial registration Current Controlled Trials IS RCT N05681227 Clinical Trials.gov INTRODUCTION Psychogenic nonepileptic seizures ( PNES ) are episodic alterations in behavior presumed to reflect a physical manifestation of underlying psychological distress . St and ardized treatment approaches for PNES care are lacking . We evaluated common approaches to PNES management that do not require significant commitment of time and re sources . METHODOLOGY Patients with PNES established with video-EEG monitoring were r and omized to one of the following three groups : 1 )  PNES diagnosis delivered per the discretion of the attending physician with advice to seek mental health assistance in the community  ( n=12 ) , 2 ) scripted PNES diagnosis provided and inpatient psychiatry consult obtained ( n=10 ) , and 3 ) weekly follow-up phone calls made in addition to scripted diagnosis and inpatient psychiatry consultation ( n=15 ) . Reduction in event frequency measured at 8weeks following hospital discharge represented the primary outcome variable . Secondary variables analyzed included exploration of change in self-reported mood , quality of life , and healthcare utilization . RESULTS No significant improvements were noted in patients simply given a PNES diagnosis and advised to seek outside care on any measure . In contrast , patients receiving a scripted diagnosis and psychiatric consultation demonstrated decreased PNES frequency accompanied by improved quality of life ( QOL ) . Patients also receiving weekly phone calls not only demonstrated decreased PNES frequency and improvements in QOL but also exhibited improved mood . DISCUSSION These findings demonstrate that providing diagnostic information regarding PNES is insufficient by itself to meaningfully affect patient outcome . Structured feedback and psychiatric consultation appeared adequate to significantly reduce PNES frequency and improve aspects of quality of life , while the addition of a weekly phone contact also led to improved mood Background Somatoform disorders are an important factor in functional disability and role impairment , though their independent contribution to disability has been unclear because of prevalent medical and psychiatric comorbidity . Objectives To assess the extent of the overlap of somatization with other psychiatric disorders and medical problems , to compare the functional disability and role impairment of somatizing and non-somatizing patients , and to determine the independent contribution of somatization to functional disability and role impairment . Design Patients were surveyed with self-report question naires assessing somatization , psychiatric disorder , and role impairment . Medical morbidity was indexed with a computerized medical record audit . Participants Consecutive adults making scheduled visits to their primary care physicians at two hospital-affiliated primary care practice s on r and omly chosen days . Measurements Intermediate activities of daily living , social activities , and occupational disability . Results Patients with somatization , as well as those with serious medical and psychiatric illnesses , had significantly more impairment of activities of daily life and social activities . When these predictors were considered simultaneously in a multivariable regression , the association with somatization remained highly significant and was comparable to or greater than many major medical conditions . Conclusions Patients with somatization had substantially greater functional disability and role impairment than non-somatizing patients . The degree of disability was equal to or greater than that associated with many major , chronic medical disorders . Adjusting the results for psychiatric and medical co-morbidity had little effect on these findings CONTEXT Somatoform disorders are an important determinant of medical care utilization , but their independent effect on utilization is difficult to determine because somatizing patients frequently have psychiatric and medical comorbidity . OBJECTIVES To assess the extent of the overlap of somatization with other psychiatric disorders ; to compare the medical utilization of somatizing and nonsomatizing patients ; and to determine the independent contribution of somatization alone to utilization . DESIGN Patients were surveyed with self-report question naires assessing somatization and psychiatric disorder .  Medical care utilization was obtained from automated encounter data for the year preceding the index visit . Medical morbidity was indexed with a computerized medical record audit . SETTING Two hospital-affiliated primary care practice s. PARTICIPANTS Consecutive adults making scheduled visits to their primary care physicians on r and omly chosen days . In all , 2668 question naires were distributed , and 1914 ( 71.7 % ) were returned . Of these , 1546 ( 80.8 % ) contained complete data and met eligibility criteria . MAIN OUTCOME MEASURES Medical care utilization and costs within our hospital system in the preceding 12 months . RESULTS Two hundred ninety-nine patients ( 20.5 % ) received a provisional diagnosis of somatization ; 42.3 % of these patients had no comorbid depressive or anxiety disorder . Somatizing patients , when compared with nonsomatizing patients , had more primary care visits ( mean [ SE ] , 4.90 [ 0.32 ] vs 3.43 [ 0.11 ] ; P<.001 ) ; more specialty visits ( mean [ SE ] , 8.13 [ 0.55 ] vs 4.90 [ 0.21 ] ; P<.001 ) ; more emergency department visits ( mean [ SE ] , 1.29 [ 0.15 ] vs 0.52 [ 0.036 ] ; P<.001 ) ; more hospital admissions ( mean [ SE ] , 0.32 [ 0.051 ] vs 0.13 [ 0.014 ] ; P<.001 ) ; higher inpatient costs ( mean [ SE ] , USD 3146 [ USD 380 ] vs USD 991 [ USD 193 ] ; P<.001 ) ; and higher outpatient costs ( mean [ SE ] , USD 3208 [ USD 180 ] vs USD 1771 [ USD 91 ] ; P<.001 ) . When these results were adjusted for the presence of comorbid anxiety and depressive disorders , major medical morbidity , and sociodemographic characteristics , patients with somatoform disorder still had more primary care visits ( P = .04 ) , more specialist visits ( P = .002 ) , more emergency department visits ( P<.001 ) , more hospital admissions ( P<.001 ) , more ambulatory procedures ( P<.001 ) , higher inpatient costs ( P<.001 ) , and higher outpatient costs ( P<.001 ) . When these findings are extrapolated to the national level , an estimated USD 256 billion a year in medical care costs are attributable to the incremental effect of somatization alone . CONCLUSIONS Patients with somatization had approximately twice the outpatient and inpatient medical care utilization and twice the annual medical care costs of nonsomatizing patients . Adjusting the findings for the presence of psychiatric and medical comorbidity had relatively little effect on this association PURPOSE To determine whether withdrawal of antiepileptic drugs ( AEDs ) in patients with psychogenic nonepileptic attacks ( PNEAs ) improves outcome . METHODS R and omized controlled trial of AED withdrawal in patients with PNEAs . Patients were r and omized to immediate or delayed ( 9 months ) withdrawal of AEDs .  We recorded spell frequency , changes in work status , use of emergency medical services , and psychological status at baseline , 9 months , and 18 months . RESULTS Of 193 patients screened , 38 fulfilled entry criteria , 13 declined participation , and 25 were r and omized . Fourteen patients were r and omized to immediate withdrawal ( IW ) and 11 patients to delayed withdrawal ( DW ) . There was a significant reduction in spell frequency from baseline to 9 months in the IW group but not in the DW group ( p = 0.028 ) . There was a significantly greater reduction in use of rescue medication in the IW group compared to the DW group between baseline and 9 months ( p = 0.002 ) . Emergency health care utilization dropped to zero in both groups by the end of the study . Psychological measures reflecting internal locus of control increased significantly more in the IW group ( p = 0.005 ) . DISCUSSION Stringent diagnostic criteria and an increasing tendency for patients to be referred before AED prescription limited the recruitment and the power of the study . Our data nonetheless provide evidence that some outcomes are improved by AED withdrawal in patients with PNEAs OBJECTIVE To compare the remission in symptoms achieved with behavior therapy and routine clinical care to that with routine clinical care given alone to patients having dissociative disorder . DESIGN A r and omized controlled trial . PLACE AND DURATION OF STUDY Psychiatry Unit , Lady Reading Hospital , Peshawar from April 2004 to September 2004 . SUBJECTS AND METHODS A total sample of 100 patients was recruited through Psychiatric OPD and Emergency unit . Patients were r and omly allocated to the intervention or control group . The number of fits were recorded each day during admission . The patients were followed-up for four weeks after discharge . Hospital anxiety and depression scale and clinical global impression scales were applied . The two- sample Kolmogorov-Smirnov test was used to show the differences in relative frequencies of fits between the two groups . RESULTS There were no statistically significant differences in sociodemographic and clinical variables in the intervention and control groups at baseline . There was a highly significant difference between the two groups in frequency of fits at discharge , on the first follow-up and on the fourth follow-up ( p=0.000 ) . Similarly , patients in the intervention group showed more improvement on hospital anxiety and depression scale compared to the control group , ( p=0.000 ) at the end of four weeks . CONCLUSION Behavioral intervention in the management of conversion disorder is more effective than the methods applied in our daily practice While fatigue is found to be an impairing symptom in functional motor disorders ( FMD ) in clinical practice , scientific evidence is lacking . We investigated fatigue severity and subtypes in FMD compared to organic neurological disease . Furthermore , the role of fatigue within FMD and its impact on quality of life and self-rated health were investigated . Data from 181 patients participating in the self-help on the internet for functional motor disorders , r and omised Trial were included . Data from 217 neurological controls with neuromuscular disorders ( NMD ) originated from a historical cohort .  Fatigue was measured using the checklist individual strength ( CIS ) . Motor symptom severity , depression and anxiety were correlated to fatigue . For multivariable regression analyses , physical functioning and pain were additionally taken into account . Severe fatigue was , respectively , present in 78 and 53 % of FMD and NMD patients ( p < 0.001 ) . FMD patients scored higher than NMD patients on all fatigue subdomains ( p < 0.001 ) . In the FMD group , fatigue subdomains were correlated to depression , anxiety and partly to motor symptom severity . Quality of life was negatively associated with fatigue [ OR 0.93 ( 0.90–0.96 ) , p < 0.001 ] and depression [ OR 0.87 ( 0.81–0.93 ) , p < 0.001 ] , but not self-rated motor symptom severity . Self-rated health was negatively associated with fatigue [ OR 0.92 ( 0.88–0.96 ) , p < 0.001 ] and pain [ OR 0.98 ( 0.97–0.99 ) , p < 0.001 ] . Fatigue was found to be a prevalent problem in FMD , more so than in organic neurological disease . It significantly affected quality of life and self-rated health , while other factors such as motor symptom severity did not . Fatigue should be taken into account in clinical practice and treatment trials OBJECTIVE To evaluate therapeutic efficacy upon augmenting the initial communication to patients regarding the diagnosis of psychogenic nonepileptic seizures ( PNES ) with a novel , brief group psychoeducation administered by the same team that provided the video-electroencephalography ( VEEG ) confirmed diagnosis and within 4 weeks of the diagnosis . METHODS Prior to discharge from the epilepsy monitoring unit ( EMU ) , a st and ardized communication strategy was utilized to explain the diagnosis of PNES to all patients prior to enrollment . Enrolled patients were then r and omized to either participation in three successive and monthly group psychoeducational sessions ( intervention group ) , or routine seizure clinic follow-up visits ( control group ) . Both groups completed question naires at time of enrollment , and then at approximately 3 months ( follow-up 1 ) and 6 months ( follow-up 2 ) after discharge , assessing for : ( 1 ) primary outcomes that include a measure of psychosocial functioning , as well as interval difference in seizure frequency/intensity ; and ( 2 ) secondary outcomes that include interval seizure-related emergency room visits or hospitalizations , development of new and medically unexplained symptoms , and results of an internal measure of knowledge and perception outcomes . RESULTS The majority ( 73 % ) of patients from the intervention group commenced on therapy sessions within 4 weeks after learning of the diagnosis . Although we did not observe significant group difference in seizure frequency/intensity , patients from the intervention group showed significant improvement on the Work and Social Adjustment Scale ( WSAS ) scores at both follow-up 1 ( p = 0.013 ) and follow-up 2 ( p = 0.038 ) after discharge from the EMU . In addition , we observed a trend toward lesser likelihood for seizure-related emergency room visits or hospitalizations for the intervention group ( p = 0.184 ) , as well as meaningful insights from an internal measure of intervention outcomes . SIGNIFICANCE These findings suggest that our cost/re source effective , brief group psychoeducational program , when administered early and by the same team who confirmed and communicated the diagnosis of PNES , may contribute to significant functional improvement among participating patients Objective : There have been few treatment trials for  psychogenic nonepileptic seizures ( PNES ) .  Some psychotherapies have been shown to improve PNES and comorbid symptom outcomes . We evaluated a pharmacologic intervention to test the hypothesis that sertraline would reduce PNES . Methods : We conducted a pilot , double-blind , r and omized , placebo-controlled trial in an academic medical hospital with epilepsy center out patients . Subjects aged 18 to 65 years diagnosed with video-EEG – confirmed PNES were treated with flexible-dose sertraline or placebo over 12 weeks . Seizure calendars and symptom scales were charted prospect ively . Secondary outcome measures included psychiatric symptom scales and psychosocial variables . Results : Thirty-eight subjects enrolled , and 26 ( 68 % ) completed the trial . Thirty-three subjects with nonzero nonepileptic seizure rates at baseline were included in intent-to-treat analysis of the primary outcome . Subjects assigned to the sertraline arm experienced a 45 % reduction in seizure rates from baseline to final visit ( p = 0.03 ) vs an 8 % increase in placebo ( p = 0.78 ) . Secondary outcome scales revealed no significant between-group differences in change scores from baseline to final visit , after adjustment for differences at baseline . Conclusions : PNES were reduced in patients treated with a serotonin selective reuptake inhibitor , whereas those treated with placebo slightly increased . This study provides feasibility data for a larger-scale study . Level of evidence : This study provides Class II evidence that flexible-dose sertraline up to a maximum dose of 200 mg is associated with a nonsignificant reduction in PNES rate compared with a placebo control arm ( risk ratio 0.51 , 95 % confidence interval 0.25–1.05 , p = 0.29 ) , adjusting for differences at baseline
target: No single measure was identified for use across the range of FND symptoms in adults .
  Across r and omised 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 re source use and quality -adjusted life years ) .
  CONCLUSIONS There are few well-vali date d FND-specific outcome measures .
background: OBJECTIVES We aim ed to identify existing outcome measures for functional neurological disorder ( FND ) , to inform the development of recommendations and to guide future research on FND outcomes .