Psychological therapy for functional neurological disorder

Question 1

types of psychological interventions for FND

Answer 1

CBT-based psychological interventions
psychoeducation
motivational interviewing

Question 2

CBT for FND

Answer 2

Symptoms caused by a self-perpetuating multi-factorial cycle
Based on the interaction between somatic, cognitions, behaviour, emotions, and environment

Question 3

3P model of CBT for FND

Answer 3

predisposing
precipitating
perpetuating

Question 4

aim of CBT for FND

Answer 4

CBT focuses on addressing or changing cognitions and behaviours that people have in interaction with their sx

Question 5

benefit of CBT

Answer 5

There are specific modifications for different FNDs e.g.
- seizure-directed approach for dissociative seizures
- vestibular rehabilitation for dizziness.

Question 6

CBT for chronic pain

Answer 6

• Little evidence for behavioural therapy except for improvement in mood immediately following tx vs controls
• CBT - small to moderate beneficial effects on pain, disability, mood and negative cognitions (catastrophising) vs usual care controls
• most improvements gone by follow-up

Question 7

CBT for PPPD

Answer 7

Adjunctive CBT combined with conventional therapy may be effective for Persistent Postural Perceptual Dizziness (disorder of spatial orientation and motor sensory abnormalities)

Question 8

what is functional cognitive disorder

Answer 8

At least one symptom of impaired cognitive function is present
Evidence of internal inconsistency with observed / measured function, or between different situations
Symptoms and impairment are not better explained by another medical disorder, although might be comorbid with another medical disorder
Symptoms / impairment cause clinically substantial distress or impairment in other important areas of function, or warrant medical investigation.

Question 9

Formulation for therapy for FCD - characteristics of FCD relevant for therapy

Answer 9

addressing patterns of hypervigilance
over-interpretation of cognitive errors and abnormal prior expectations or catastrophic beliefs
patterns of maladaptive coping through over-control of cognitive processing
other avoidance and safety behaviours
any contributing factors in the family system

Question 10

CBT for FCD post concussion

Answer 10

CBT vs cognitive rehabilitation
similar improvements on MMQ-S (Multifactorial Memory Questionnaire Satisfaction)
improvement in avoidance and catastrophising

Question 11

CODES trial

Answer 11

Phase I - ax and dx, consent, demographics and seizure diary for 3 months
Phase II - clinical psychiatric ax, consent, randomisation to CBT + standards care vs standard care alone

Question 12

CBT model for DS

Answer 12

Seizures are viewed as dissociative responses to arousal
Occur when patient is confronted with intolerable / fearful circumstances.
Seizures occur with high numbers of somatic symptoms of anxiety / panic
Seizures then maintained by a vicious circle
Certain activities/behaviours or experiences are modified or avoided

Question 13

CBT interventions

Answer 13

graded exposure to feared (avoided) situations
treatment of mood disorder
problem-solving techniques cognitive interventions
to alter dysfunctional thinking and deal with trauma
dissociative control techniques

Question 14

CBT group

Answer 14

CBT therapists
12 sessions of CBT (over 4-5 months) +1 booster session
manualised tx but allows intervention to be formulation-based

Question 15

standard care protocol

Answer 15

Delivered by neurologists / psychiatrists
Includes information sheet and direction
Provide general information about management of DS/ AED withdrawal
Provide support, consideration of psychiatric comorbidities / associated drug treatment and general review but no CBT techniques

Question 16

primary outcome finding

Answer 16

We observed fewer seizures at 12 m in the CBT+SMC group but the difference was not statistically significant

Question 17

statistically significant secondary outcomes

Answer 17

Longest number of consecutive days free of DS in last six months
Lower impact of DS on everyday functioning (Work and Social Adjustment Scale)
Lower impact of DS on everyday functioning (Work and Social Adjustment Scale)
Doctor-rated global clinical improvement
Patient satisfaction with treatment
Importantly – no evidence of more AEs/SAEs/harms due to CBT

Question 18

limitations of the CODES trial

Answer 18

No waiting list or treatment-as-usual control group
standard care group as control could be considered active intervention

Question 19

strengths of CODES trial

Answer 19

Pragmatic design
Large sample size
High follow-up rates
Outcome assessments by a masked researcher
Large number of centres and therapists involved
Good compliance with CBT

Question 20

moderators

Answer 20

moderators of treatment effects to inform which patient baseline characteristics might interact with CBT to influence outcome

Question 21

predictors

Answer 21

predictors of outcome irrespective of treatment received

Question 22

moderators of CBT response

Answer 22

gender
phq-15
current psych dx

Question 23

predictors of cbt

Answer 23

qualifications
not on benefits
employment
lower anxiety/ depression score

Question 24

possible mechanisms of change in CODES trial

Answer 24

Avoidance of people,
places situations
Beliefs about emotions
Depression
Anxiety

Question 25

psychoeducation for dissociative seizures

Answer 25

Engage patient, provide psychological explanation of symptoms, explain mind–body link Identify warning signs prior to seizures teach self-management skills identify physical sensations associated with stress/ anxiety Identify avoidance behaviours adopted because of seizures develop goal to reduce one type of avoidance behaviour Discuss how to improve functioning in patient's most valued areas of life Reflection All measures improved from baseline to post-intervention, but only significant for CORE-OM (p< 0.05) and BIPQ (p < 0.01).

Question 26

motivational interviewing to improve adherence to CBT

Answer 26

Motivational interviewing has been designed to deal with issues of ambivalence about behavioural change effective in improving engagement and adherence in a range of conditions psychotherapy vs psychotherapy and MI

Question 27

what are the four processes of motivational interviewing

Answer 27

engaging focusing evoking planning

Question 28

motivational interviewing - engaging

Answer 28

Establishing an open, empathic, patient-centred relationship

Question 29

motivational interviewing - focusing

Answer 29

Helping the participant to identify DS treatment as a target for behaviour change

Question 30

motivational interviewing - evoking

Answer 30

Using reflective listening to elicit the participant’s reasons for wanting to treat DS

Question 31

motivational interviewing - planning

Answer 31

Eliciting concrete plans for behavioural change incl. participating in psychotherapy

Question 32

underpinning of motivational interviewing

Answer 32

Heavy reliance on reflective listening and emphasis on evoking and strengthening patients’ motivations supporting psychotherapy engagement and adherence

Question 33

mindfulness for dissociative seizures

Answer 33

PNES frequency, intensity, and quality of life improved at treatment end.

Question 34

CBT and adjunctive physical activity (apa) for FMD

Answer 34

cbt vs cbt and adjunctive physical activity (apa) structured low /moderate intensity walking as a group or individually Both Tx groups showed improvement for primary and secondary outcomes over time (p<0.001), not SMC group no differences between walking alone vs as a group

Question 35

psychodynamic psychotherapy

Answer 35

Focuses on historical and early life experiences, parenting dynamics, enduring personality traits and making links between them

Question 36

goal of psychodynamic psychotherapy

Answer 36

to reshape the intrapsychic structure of the patient to produce favourable symptom change based on specific theories about the nature of early childhood nurturing experiences and parenting dynamics

Question 37

difficulties with CBT interventions for functional neurological symptoms

Answer 37

Undertaking treatment follow-up in patients with conversion disorders Different/changing diagnostic criteria (affects generalisability) as well as diverse patient characteristics and places/modes of treatment delivery How best to measure outcome Establishing an adequate control group

Question 38

single vs multiple tx

Answer 38

studies look at single modalities of tx which is not really the case it may be necessary to combine treatments for pt with chronic somatic conditions