Outcome measurement in functional neurological disorder: a systematic review and recommendations.

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.

Insights into Chronic Functional Movement Disorders: The Value of Qualitative Psychiatric Interviews.

BACKGROUND: Patients with functional movement disorders (FMDs) are commonly seen by neurologists and psychosomatic medicine psychiatrists. Research literature provides scant information about the subjective experiences of individuals with this often chronic problem. OBJECTIVE: To enhance our understanding of psychologic aspects of FMDs by conducting qualitative interviews of research subjects. METHODS: In total, 36 patients with FMDs were recruited from the Human Motor Control clinic at the National Institutes of Health. Each subject participated in a qualitative psychiatric interview and a structured diagnostic psychiatric interview. RESULTS: Of our 36 subjects, 28 had current or lifetime psychiatric disorders in addition to conversion disorder and 22 had current disorders. Qualitative interviews provided rich information on patients' understanding of their illnesses and impaired cognitive processing of emotions. CONCLUSION: Our study supports the addition of open-ended qualitative interviews to delineate emotional dynamics and conceptual frameworks among such patients. Exploratory interviews generate enhanced understanding of such complex patients, above and beyond that gained by assessing DSM diagnostic comorbidities.

EEG screening for temporal lobe epilepsy in patients with acute psychosis.

Seizures may present with ictal or interictal psychosis mimicking primary psychiatric disorders. The authors reviewed EEG, brain-imaging, and clinical data of 240 patients presenting with acute psychotic episode to assess the diagnostic value of EEG in differentiating ictal psychosis from primary psychosis. Seven patients had interictal spikes, but there were no patients with ictal discharges. There were no significant associations between the tested variables except that taking neuroleptics/antidepressants was associated with abnormal EEG, and older age and taking anti-epileptic drugs were associated with abnormal CT scans. These findings do not support routine use of EEG in patients presenting with acute psychosis.

Primary care physicians' evaluation and treatment of depression: Results of an experimental study using video vignettes.

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

Mania: psychiatric manifestations of the antiphospholipid syndrome.

BACKGROUND: Antiphospholipid syndrome (APS) is a prothrombotic condition characterized by recurrent vascular thrombosis and/or pregnancy morbidity in the presence of circulating antiphospholipid antibodies. Central nervous system (CNS) involvement is a prominent feature of APS, and many neurological manifestations have been described in published reports. There are limited data on psychiatric syndromes occurring in association with APS, and there have been no previous reports of mania associated with APS. METHOD: The authors present the case of a 31-year-old man who experienced an acute manic episode in association with APS. They review the literature on psychiatric manifestations of APS, discuss potential mechanisms of CNS pathogenesis, and consider diagnostic and treatment implications of the co-occurrence of APS and psychiatric symptoms.

Gray matter differences in patients with functional movement disorders.

OBJECTIVE: To explore alterations in gray matter volume in patients with functional movement disorders. METHODS: We obtained T1-weighted MRI on 48 patients with clinically definite functional movement disorders, a subset of functional neurologic symptom disorder characterized by abnormal involuntary movements, and on 55 age- and sex-matched healthy controls. We compared between-group differences in gray matter volume using voxel-based morphometry across the whole brain. All participants in addition underwent a thorough neuropsychological battery, including the Hamilton Anxiety and Depression Scales and the Childhood Trauma Questionnaire. To determine whether confounding factors such as comorbid depression, anxiety, or childhood trauma exposure contributed to the observed structural changes, nonparametric correlation analysis was performed. RESULTS: Patients with functional movement disorders exhibited increased volume of the left amygdala, left striatum, left cerebellum, left fusiform gyrus, and bilateral thalamus, and decreased volume of the left sensorimotor cortex (whole-brain corrected p ≤ 0.05). Volumetric differences did not correlate with measures of disease duration or patient-rated disease severity. CONCLUSION: This study demonstrates that patients with functional movement disorders exhibit structural gray matter abnormalities in critical components of the limbic and sensorimotor circuitry. These abnormalities may represent a premorbid trait rendering patients more susceptible to disease, the disease itself, or a compensatory response to disease.

Impaired self-agency in functional movement disorders: A resting-state fMRI study.

OBJECTIVE: To investigate the neural mechanisms underlying impaired self-agency in patients with functional movement disorders using resting-state functional MRI (fMRI). METHODS: We obtained resting-state fMRI on 35 patients with clinically definite functional movement disorders and 35 age- and sex-matched healthy controls. Between-group differences in functional connectivity from the right temporo-parietal junction (TPJ), a region previously demonstrated to play a critical role in self-agency by comparing internal predictions of movement with actual external events, were assessed using t tests. All participants were screened for psychiatric diagnoses using a structured clinical interview and completed the Beck Depression Inventory and Childhood Trauma Questionnaire. RESULTS: Compared to the healthy controls, patients with functional movement disorders showed decreased functional connectivity between the right TPJ and the right sensorimotor cortex, cerebellar vermis, bilateral supplementary motor area, and right insula. These findings were independent of depression, anxiety, and childhood trauma scores included in our assessment as covariates. CONCLUSIONS: The decreased functional connectivity between the right TPJ and bilateral sensorimotor regions observed in patients with functional movement disorders supports a model whereby impaired motor feed-forward together with altered sensory feedback from sensorimotor regions and areas of sensorimotor integration to the right TPJ contributes to patients' impaired sense of self-agency.

Impaired resting vagal tone in patients with functional movement disorders.

INTRODUCTION: The autonomic nervous system plays an integral role in the maintenance of homeostasis during times of stress. The functioning of the autonomic nervous system in patients with functional movement disorders (FMD) is of particular interest given the hypothesis that converted psychological stress plays a critical role in FMD disease pathogenesis. We sought to investigate autonomic nervous system activity in FMD patients by examining heart rate variability (HRV), a quantitative marker of autonomic function. METHODS: 35 clinically definite FMD patients and 38 age- and sex-matched healthy controls were hospitalized overnight for continuous electrocardiogram recording. Standard time and frequency domain measures of HRV were calculated in the awake and asleep stages. All participants underwent a thorough neuropsychological battery, including the Hamilton Anxiety and Depression scales and the Beck Depression Inventory. RESULTS: Compared to controls, patients with FMD exhibited decreased root mean square of successive differences between adjacent NN intervals (RMSSD) (p = 0.02), a marker of parasympathetic activity, as well as increased mean heart rate (p = 0.03). These measures did not correlate with the depression and anxiety scores included in our assessment as potential covariates. CONCLUSION: In this exploratory study, patients with FMD showed evidence of impaired resting state vagal tone, as demonstrated by reduced RMSSD. This decreased vagal tone may reflect increased stress vulnerability in patients with FMD.

Treatment patterns and outcomes of depressed medically ill and non-medically ill patients in community psychiatric practice.

The prevalence of depression among the medically ill, the recognition of depression in general medical practice, and the association between depression and medical illness have all been a focus for research in recent years. Less is known about the process and outcomes of depression care in the medically ill compared with the non-medically ill, but some studies suggest that those with concomitant physical illness have poorer outcomes. In a study of community psychiatric practice, a sample of 53 patients with no medical comorbidity (NMI) was compared with 50 patients, categorized by higher (HMI) or lower (LMI) levels of physical comorbidity, approximately 5 months after beginning treatment for a current episode of major depression. No differences were found in treatments received or in mental health outcomes between the three groups. The HMI group showed greater impairment in social and occupational functioning at baseline and significantly greater improvement in these variables at follow-up. Since medical comorbidity does not appear to adversely affect treatment decisions or outcomes in community psychiatric practice, depressed, physically ill patients should be encouraged to seek treatment, regardless of their medical condition or level of disability.

Predictors of primary care physicians' self-reported intention to conduct suicide risk assessments.

Primary care physicians play a significant role in depression care, suicide assessment, and suicide prevention. However, little is known about what factors relate to and predict quality of depression care (assessment, diagnosis, and treatment), including suicide assessment. The authors explored the extent to which select patient and physician factors increase the probability of one element of quality of care: namely, intention to conduct suicide assessment. Data were collected from 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying major depression with moderate levels of severity. The authors examined which patient factors and physician factors increase the likelihood of physicians' intention to conduct a suicide assessment. Data from the study revealed that physician-participants inquired about suicide 36% of the time. A random effects logistic model indicated that several factors were predictive of physicians' intention to conduct a suicide assessment: patient's comorbidity status (odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.37-1.00), physicians' age (OR = 0.67; 95% CI = 0.49-0.92), physicians' race (OR = 1.84; 95% CI = 1.08-3.13), and how depressed the physician perceived the virtual patient to be (OR = 0.58; 95% CI = 0.39-0.87). A substantial number of primary care physicians in this study indicated they would not assess for suicide, even though most physicians perceived the virtual patient to be depressed or very depressed. Further study is needed to establish factors that may be modified and targeted to increase the likelihood of physicians' providing one element of quality of care--suicide assessment--for depressed patients.

Family medicine and internal medicine physicians' attitudes and beliefs about depression: implications for treatment decisions.

Studies have long shown that some patients receive less than optimal care for depression in primary care settings. However, few studies have uncovered factors that predict and explain this deficiency. The authors administered a survey to 408 primary care physicians. They examined how physicians' attitudes (eg, feeling positively or negatively about treating depression in their patients), physicians' beliefs (eg, beliefs about what their patients think and prefer in terms of depression care), and demographic characteristics (independent variables) predicted optimal depression care (dependent variable). Using logistical regression analyses, they identified differences in treatment decisions between family and internal medicine physicians. Physicians' specialty and race (family physicians and white physicians were more likely to prescribe a medication) were unique determinants of whether the physician treated depression by prescribing medication; physicians' specialty and race (family physicians and nonwhite physicians were more likely to provide office-based counseling) were unique determinants of whether the physician treated depression by providing office-based counseling; physicians' beliefs about depression care and physician age were unique statistically significant determinants of whether the physician treated depression by providing a referral to a mental health specialist. These findings help clarify how physicians' specialty and beliefs about depression care influence treatment. In addition, the results in this study suggest that there are differences between family and internal medicine physicians in terms of their practice patterns and beliefs in types of treatment that patients would be willing to receive. Implications for future research on primary care depression treatment are discussed.

An approach to the patient with anxiety.

Patients seen in primary care and in specialty medical settings often have prominent anxiety. This article presents the epidemiology, etiology, manifestations, and treatment of anxiety disorders.

Virtual standardized patients: an interactive method to examine variation in depression care among primary care physicians.

BACKGROUND: Some primary care physicians provide less than optimal care for depression (Kessler et al., Journal of the American Medical Association 291, 2581-90, 2004). However, the literature is not unanimous on the best method to use in order to investigate this variation in care. To capture variations in physician behaviour and decision making in primary care settings, 32 interactive CD-ROM vignettes were constructed and tested. AIM AND METHOD: The primary aim of this methods-focused paper was to review the extent to which our study method - an interactive CD-ROM patient vignette methodology - was effective in capturing variation in physician behaviour. Specifically, we examined the following questions: (a) Did the interactive CD-ROM technology work? (b) Did we create believable virtual patients? (c) Did the research protocol enable interviews (data collection) to be completed as planned? (d) To what extent was the targeted study sample size achieved? and (e) Did the study interview protocol generate valid and reliable quantitative data and rich, credible qualitative data? FINDINGS: Among a sample of 404 randomly selected primary care physicians, our voice-activated interactive methodology appeared to be effective. Specifically, our methodology - combining interactive virtual patient vignette technology, experimental design, and expansive open-ended interview protocol - generated valid explanations for variations in primary care physician practice patterns related to depression care.

Formal training in women's issues in psychiatry: a survey of psychiatry residency training directors.

OBJECTIVE: The authors describe the availability of formal residency training opportunities in women's issues in psychiatry and explore the potential relationships between the availability of training and characteristics of residency programs. METHOD: The authors surveyed psychiatry residency training directors to identify program characteristics and training opportunities. RESULTS: Certain didactic subjects were available in greater than 80% of residencies. Clinical training opportunities were less available and often not required. CONCLUSIONS: Selected didactic training in gender issues is commonly available in a majority of residencies. Nevertheless, general clinical instruction and didactic instruction in several important topics are less available.