A meta-analytic evaluation of the effectiveness and durability of psychotherapy for adults presenting with functional dissociative seizures.

BACKGROUND: Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes. METHODS: This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes. RESULTS: Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis. CONCLUSIONS: The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Psychological Therapy for Functional Neurological Disorder: Examining Impact on Dissociation, Psychological Distress and General Functioning.

Functional neurological disorder (FND) represents a broad group of motor and sensory clinical symptoms which cannot be explained by other neurological diagnoses. Dissociation is considered a key mechanism in their development and maintenance. Despite psychological therapy being the recommended choice of treatment for FND, evidence for its effectiveness is in its infancy. This study explored the dissociative profile of forty-seven patients with FND and evaluated whether individual psychological therapy improved dissociative symptoms, psychological distress and general functioning among twenty-five adults with FND. Patients completed the Multiscale Dissociation Inventory, the EuroQol five-dimensional descriptive system, the General Anxiety Disorder-7 scale and the Patient Health Questionnaire-9. Our sample showed high levels of disengagement, depersonalization and memory disturbance at baseline. Treatment was associated with significant improvements in general functioning, and symptoms of dissociation and anxiety. Improvements in dissociative experiences were found to be possibly due to reduction in anxiety. Improvements in depression were the strongest predictor of improvements in general functioning. Limitations and areas for further research are discussed.

Incestuous Abuse Continuing into Adulthood: Clinical Features and Therapists' Conceptualisations.

Prolonged incest, where children are sexually abused by familial perpetrators into adulthood, has been documented in clinical and criminological scholarship, however it is often overlooked in research, policy and practice approaches to familial sexual abuse. This article draws on interviews with ten Australian therapists about their clinical work with clients subject to incestuous abuse continuing into adulthood. It outlines their descriptions of these cases, the nature of the reported abuse and factors that facilitated prolonged and ongoing incest, including at the time of therapy. The therapists and their clients were female. The clients were highly dissociative and experienced significant psychiatric and medical comorbidity, and extensive socio-economic disadvantage. Reported abuse was sadistic, ongoing, often involved multiple perpetrators, and sometimes had links to organized abuse. Therapists' conceptualizations of the factors related to the abuse included: enmeshed and disorganized attachment to the perpetrator; symptoms of severe dissociation; having absent, abusive or non-protective mothers; and social isolation which limited help-seeking. The study concludes that attachment, trauma and dissociation-informed therapy is essential, while further research is needed to further explore effective interventions and responses to this clinical cohort.

Pathways to care and barriers in treatment among patients with Dissociative disorders.

INTRODUCTION: Dissociative disorder patients often present with sudden and embarrassing symptoms, and it is difficult for the patient and care giver to understand initially, recognize the need for help and reach for appropriate treatment timely. This can result in high risk of engaging in dangerous behaviors such as self-harm and suicidal acts, impaired global functioning, and poor quality of life. Knowledge about the types of barriers which are there in treatment seeking, can help in planning strategies for their removal and to facilitate the treatment process. METHODS: Cross-sectional study among patients (n=133) with Dissociative disorders which were recruited from January 2023 to June 2023 in a tertiary care hospital. Pathways to care and barriers in treatment for Dissociative disorders were assessed by interviewing patients using semi-structured proforma. The Dissociative Experience Scale and World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)) were used to assess disease severity and impact of illness on various domains of life respectively. Group comparison was made to assess differences in social- clinical profile of patients choosing different modalities of treatment. RESULTS: 133 patients of Dissociative disorders with mean age 29.6±9.2, showed their first-choice of help seeking from general practitioner/ neurologist (40.6%), traditional faith healers (35.3%), psychiatrist (18.1%) and 5.2% preferred alternative treatments. This trend changed with 2nd and 3rd contact of help seeking with greater preference for psychiatrist in their 2nd (n=45, 33.8%) and 3rd (n=69, 51.8%) contact. The median duration of untreated illness was 56 weeks (IQR 24-182 weeks). Social-clinical profile of patients varied with their choice of treatment, having lower education level (P = 0.013), longer duration of untreated illness (p=0.003), more severity of symptoms (p=0.032) and greater disability scores(p=0.002) in patients whose first treatment choice was traditional faith healers. More than 70% patients faced availability barriers, stigma, unawareness about mental illness and influence of others in treatment of choice as barriers in initiating and continuing treatment. CONCLUSION: Patients with Dissociative disorders seek treatment from a multitude of healthcare providers including traditional faith healers, general physicians, and alternative medicine practitioners before reaching psychiatrist and undergoes various barriers in treatment. There is need to implement necessary measures for sensitization and awareness about Dissociative disorders to prevent prolonged and undue delays in initiation of appropriate management.

Helpful and meaningful aspects of a psychoeducational programme to treat complex dissociative disorders: a qualitative approach.

Purpose: Complex dissociative disorders (CDDs) are prevalent among psychotherapy clients, and research suggests carefully paced treatment for CDDs is helpful. The purpose of the present study is to qualitatively explore helpful and meaningful aspects of the TOP DD Network programme, a web-based adjunctive psychoeducational programme for the psychotherapeutic treatment of clients with CDDs.Methods: TOP DD Network programme participants (88 clients and 113 therapists) identified helpful and meaningful aspects of their participation in response to two open textbox questions. Framework analysis was used to qualitatively analyze client and therapist responses.Findings: Participants found the TOP DD Network programme helpful and meaningful in nuanced ways. Three themes were created: (1) Components of the Programme (subthemes: content, structure), (2) Change-Facilitating Processes (subthemes: heightened human connection, receiving external empathy and compassion, contributing to something bigger, improved therapeutic work and relationship), and (3) Outcomes (subthemes: insight, increased hope, self-compassion, increased safety and functioning). The most emphasized theme was components of the programme, which captured its content and structure.Conclusion: Clients and therapists in the TOP DD Network programme described the programme's components and processes as helpfully facilitating positive outcomes in the treatment of CDDs. Therapists may consider integrating the components and processes in the programme into their practice with clients with CDDs.

The aim of the present study was to qualitatively explore significant aspects of the TOP DD Network programme through the experiences of complex dissociative disorder (CDD) clients and psychotherapists.Helpful and meaningful aspects of the programme included its components (i.e. content and structure), processes, and outcomes.This psychoeducational programme can be effective and result in improved therapeutic processes and outcomes for individuals with CDDs in psychotherapy.

Sleep-Related Dissociative Disorders.

In sleep-related dissociative disorders, phenomena of the psychiatrically defined dissociative disorders emerge during the sleep period. They occur during sustained wakefulness, either in the transition to sleep or following an awakening from sleep. Behaviors during episodes vary widely, and can result in injury to self or others. Daytime dissociative episodes and a background of trauma are almost always present; there is typically major co-existing psychopathology. Diagnosis is based on both clinical history and polysomnography; differential diagnosis primarily involves other parasomnias and nocturnal seizures. Information available about treatment is limited; in a few reported cases, psychological interventions have proven effective.

Treatment of dissociative identity disorder: leveraging neurobiology to optimize success.

INTRODUCTION: Dissociative identity disorder (DID) is a treatable mental health condition that is associated with a range of psychobiological manifestations. However, historical controversy, modern day misunderstanding, and lack of professional education have prevented accurate treatment information from reaching most clinicians and patients. These obstacles also have slowed empirical efforts to improve treatment outcomes for people with DID. Emerging neurobiological findings in DID provide essential information that can be used to improve treatment outcomes. AREAS COVERED: In this narrative review, the authors discuss symptom characteristics of DID, including dissociative self-states. Current treatment approaches are described, focusing on empirically supported psychotherapeutic interventions for DID and pharmacological agents targeting dissociative symptoms in other conditions. Neurobiological correlates of DID are reviewed, including recent research aimed at identifying a neural signature of DID. EXPERT OPINION: Now is the time to move beyond historical controversy and focus on improving DID treatment availability and efficacy. Neurobiological findings could optimize treatment by reducing shame, aiding assessment, providing novel interventional brain targets and guiding novel pharmacologic and psychotherapeutic interventions. The inclusion of those with lived experience in the design, planning and interpretation of research investigations is another powerful way to improve health outcomes for those with DID.

How does cognitive behavior therapy for dissociative seizures work? A mediation analysis of the CODES trial.

BACKGROUND: We compared dissociative seizure specific cognitive behavior therapy (DS-CBT) plus standardized medical care (SMC) to SMC alone in a randomized controlled trial. DS-CBT resulted in better outcomes on several secondary trial outcome measures at the 12-month follow-up point. The purpose of this paper is to evaluate putative treatment mechanisms. METHODS: We carried out a secondary mediation analysis of the CODES trial. 368 participants were recruited from the National Health Service in secondary / tertiary care in England, Scotland, and Wales. Sixteen mediation hypotheses corresponding to combinations of important trial outcomes and putative mediators were assessed. Twelve-month trial outcomes considered were final-month seizure frequency, Work and Social Adjustment Scale (WSAS), and the SF-12v2, a quality-of-life measure providing physical (PCS) and mental component summary (MCS) scores. Mediators chosen for analysis at six months (broadly corresponding to completion of DS-CBT) included: (a) beliefs about emotions, (b) a measure of avoidance behavior, (c) anxiety and (d) depression. RESULTS: All putative mediator variables except beliefs about emotions were found to be improved by DS-CBT. We found evidence for DS-CBT effect mediation for the outcome variables dissociative seizures (DS), WSAS and SF-12v2 MCS scores by improvements in target variables avoidance behavior, anxiety, and depression. The only variable to mediate the DS-CBT effect on the SF-12v2 PCS score was avoidance behavior. CONCLUSIONS: Our findings largely confirmed the logic model underlying the development of CBT for patients with DS. Interventions could be additionally developed to specifically address beliefs about emotions to assess whether it improves outcomes.

Hypnosis and suggestion as interventions for functional neurological disorder: A systematic review.

OBJECTIVE: Functional neurological disorder (FND) involves the presence of neurological symptoms that cannot be explained by neurological disease. FND has long been linked to hypnosis and suggestion, both of which have been used as treatments. Given ongoing interest, this review examined evidence for the efficacy of hypnosis and suggestion as treatment interventions for FND. METHOD: A systematic search of bibliographic databases was conducted to identify group studies published over the last hundred years. No restrictions were placed on study design, language, or clinical setting. Two reviewers independently assessed papers for inclusion, extracted data, and rated study quality. RESULTS: The search identified 35 studies, including 5 randomised controlled trials, 2 non-randomised trials, and 28 pre-post studies. Of 1584 patients receiving either intervention, 1379 (87%) showed significant improvements, including many who demonstrated resolution of their symptoms in the short-term. Given the heterogeneity of interventions and limitations in study quality overall, more formal quantitative synthesis was not possible. CONCLUSIONS: The findings highlight longstanding and ongoing interest in using hypnosis and suggestion as interventions for FND. While the findings appear promising, limitations in the evidence base, reflecting limitations in FND research more broadly, prevent definitive recommendations. Further research seems warranted given these supportive findings.

A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults.

Dissociative Identity Disorder (DID) is a highly disabling diagnosis, characterized by the presence of two or more personality states which impacts global functioning, with a substantial risk of suicide. The International Society for the Study of Trauma and Dissociation (ISSTD) published guidelines for treating DID in 2011 that noted individual Psychodynamically Informed Psychotherapy (PDIP) was a cornerstone of treatment. This paper systematically reviews the evidence base for PDIP in the treatment of adults with DID according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-five articles were located and reviewed: seven prospective longitudinal publications, 13 case series and 15 case studies. Results suggested that PDIP has been widely deployed in DID to reported good effect with a range of treatment protocols and using multiple theoretical models. Despite the positive findings observed, the evidence base remains at the level of observational-descriptive design. Creative approaches in recent years have been developed, which add empirical weight to the use of PDIP as an effective treatment. The elevation to observational-analytic designs in the Evidence-Based Medicine hierarchy has yet to take place. Bearing in mind the challenges of research in PDIP, suggestions are offered for how the evidence base might develop.