Functional neurological disorder is a feminist issue.

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

Early Psychological Interventions for Somatic Symptom Disorder and Functional Somatic Syndromes: A Systematic Review and Meta-Analysis.

OBJECTIVE: Psychological treatments for somatic symptom disorder and functional somatic syndromes (SSD/FSS) achieve moderate effects only, potentially because of the high chronicity in these patients. Therefore, we aimed to evaluate whether early treatment, that is, treatment in populations at risk or with recent onset, improves outcome. METHODS: We conducted a systematic review and meta-analysis of (cluster-)randomized controlled trials evaluating early psychological interventions in the prevention and treatment of SSD/FSS in adults compared with inactive control conditions, standard care, or placebo. Individuals at risk for SSD/FSS, suffering from subthreshold symptoms or new onsets of SSD/FSS, or presenting with SSD/FSS for the first time were included. RESULTS: We identified 30 eligible studies, mostly examining pain-related conditions. Interventions were diverse, ranging from bibliotherapy to cognitive-behavioral therapy. We found positive effects on depression post-treatment (Hedges' g = 0.12 [95% confidence interval = 0.03-0.2], k = 5) as well as on somatic symptom severity (g = 0.25 [0.096-0.41], k = 17) and health care utilization (g = 0.31 [0.18-0.44], k = 3) at follow-up. However, because of a high risk of bias, sensitivity to corrections for meta-bias, and missing outcome data, findings should be interpreted cautiously. CONCLUSIONS: Our review shows that targeting SSD/FSS at an early stage represents a conceptual and practical challenge. Readily accessible interventions addressing transsymptomatic processes of SSD/FSS development and consolidation are highly needed. Future studies are needed to evaluate individuals with diverse symptoms, examine symptom history thoroughly, use placebo controls, and report outcomes completely to determine the efficacy of early psychological interventions for SSD/FSS.PROSPERO Registration:CRD42020140122.

The prognosis of functional limb weakness: a 14-year case-control study.

Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional limb weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional limb weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of limb weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional limb weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional limb weakness group (1%) and in one neurological control (2%). Eleven patients with functional limb weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional limb weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional limb weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional limb weakness. Misdiagnosis in functional limb weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.

Functional foreign accent syndrome.

Foreign accent syndrome (FAS) is a rare disorder where the affected person speaks in an accent that the listener perceives as foreign. Although most cases have left hemisphere lesions, some may be functional. We describe a case of functional FAS and present a video of her speech. We identify characteristics that help to distinguish functional from structural cases. These include preceding motor disturbances causing the maladaptive speech response, inconsistencies in accent production, the adoption of unusual mannerisms in speech and the speech disturbances being transient and reversible. We conclude that FAS is a complex disorder encompassing both functional and structural causes.

Wood profiling by non-targeted high-resolution mass spectrometry: Part 1, Metabolite profiling in Cedrela wood for the determination of the geographical origin.

The determination of the geographical origin of wood can be highly relevant for several reasons: On the one hand, it can help to prevent illegal logging and timber trade, on the other hand, it is of special interest for archaeological artefacts made of wood, as well as for a variety of biological questions. For this reason, different extraction methods were first tested for the analysis of polar and non-polar metabolites using liquid chromatography coupled electrospray ionization quadrupole time-of-flight mass spectrometry (UHPLC-ESI-QTOF-MS). A two-phase extraction with chloroform, methanol and water proved to be particularly successful. Subsequently, cedrela (Cedrela odorata) samples from South America were measured to distinguish geographic origin. Using multivariate data analysis, numerous origin-dependent differences could be extracted. The identification of the marker substances indicated that several metabolic pathways were affected by the geographical influences, some of them probably indicating pest infections.

An experimental study on the effectiveness of emotion regulation in patients with acute delusions.

BACKGROUND: Patients with psychotic disorders report to apply more maladaptive and less adaptive emotion-regulation (ER) strategies compared to healthy controls. However, few studies have used experimental designs to investigate the success in ER and the results of those at hand are equivocal. AIM: This study investigated whether patients with delusions show problems in downregulating negative affect via cognitive ER-strategies. METHOD: Patients with schizophrenia spectrum disorders and acute delusions (n = 78) and healthy controls (n = 41) took part in an ER-experiment, in which they were instructed to downregulate anxiety and sadness via three ER-strategies (reappraisal, distraction, acceptance) or not to regulate their emotions (control-condition). ER-success was measured as the change in subjective emotion-intensity and physiological indicators (skin conductance and heart rate) from before to after regulation and was analyzed with mixed-repeated-measures ANOVAs. RESULTS: We found a significant effect of the ER-strategy in the sense that the subjective emotion-intensity was significantly lower after applying the reappraisal- and distraction-strategies than after the just view-condition (p's < .001). This effect was not found for the acceptance strategy (p = .060). There was no ER-strategy ∗ time ∗ group interaction-effect F(4.918, 575.416) = 0.778, p = .564, ƞ2partial = 0.007. In all conditions, skin conductance decreased from pre- to post regulation (p < .001). CONCLUSION: Our results indicate that patients with acute delusions can successfully apply cognitive ER-strategies. Before pursuing the relevant clinical implications of this finding, further research is needed to explore the role that the type of instruction has on ER-success and the extent to which the findings can be generalized to real life settings.

Sleep and circadian rhythm disruption predict persecutory symptom severity in day-to-day life: A combined actigraphy and experience sampling study.

Sleep-related problems are prevalent in patients with psychotic disorders, yet their contribution to fluctuations in delusional experiences is less clear. This study combined actigraphy and experience-sampling methodology (ESM) to capture the relation between sleep and next-day persecutory symptoms in patients with psychosis and prevailing delusions. Individuals with current persecutory delusions (PD; n = 67) and healthy controls (HC; n = 39) were assessed over 6 consecutive days. Objective sleep and circadian rhythm measures were assessed using actigraphy. Every morning upon awakening, subjective sleep quality was measured using ESM. Momentary assessments of affect and persecutory symptoms were gathered at 10 random time points each day using ESM. Robust linear mixed modeling was performed to assess the predictive value of sleep measures on affect and daytime persecutory symptoms. PD showed significantly lower scores for subjective quality of sleep but significantly higher actigraphic-measured sleep duration and efficiency compared with HC. Circadian rhythm disruption was associated with more pronounced severity of persecutory symptoms in HC. Low actigraphy-derived sleep efficiency was predictive of next-day persecutory symptoms in the combined sample. Negative affect was partly associated with sleep measures and persecutory symptoms. Our results imply an immediate relationship between disrupted sleep and persecutory symptoms in day-to-day life. They also emphasize the relevance of circadian rhythm disruption for persecutory symptoms. Therapeutic interventions that aim to reduce persecutory symptoms could benefit from including modules aimed at improving sleep efficacy, stabilizing sleep-wake patterns, and reducing negative affect. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Heart rate variability as an index of emotion (dys)regulation in psychosis?

The vagally-mediated heart rate variability (HRV), an indicator of the autonomic nervous system (ANS), has been proposed as a transdiagnostic marker for emotion regulation (ER). In people with psychotic disorders (PSY), HRV is profoundly reduced compared to healthy controls (HC). Similarly, questionnaire-based assessments of adaptive ER point to a deficit in PSY. To address HRV as a potential marker for ER in psychosis, we investigated a large sample including PSY (n = 40) and HC (n = 32) as well as vulnerable (n = 19 clinical high-risk) and clinical (n = 28 anxiety disorders) controls. We tested the differential effectiveness of an instructed adaptive ER strategy, whether resting-state HRV predicts adaptive ER, and whether HRV serves as a state index of ER effort. The participants repeatedly played a social exclusion ballgame while they applied either cognitive reappraisal or no regulation ("just-play") in randomized order. PSY displayed overall higher levels of negative affect and paranoia than HC but both groups applied reappraisal successfully (i.e., more benefit: lower negative affect and paranoia after reappraisal compared to "just-play"). Resting-state HRV did not predict successful reappraisal in the total sample. However, within PSY, a higher resting-state HRV predicted more benefit from reappraisal. State HRV did not differ between the reappraisal and "just-play" condition. Contrary to our expectations, participants with psychosis applied an instructed adaptive ER strategy successfully. As expected, the ANS marker of HRV predicted that benefit; however, this was only the case in PSY. Overall, HRV was not a robust but a tentative marker of ER in the present investigation.

Effectiveness of emotion regulation in daily life in individuals with psychosis and nonclinical controls-An experience-sampling study.

Individuals with psychosis report employing more maladaptive and less adaptive emotion regulation (ER) strategies compared to nonclinical controls (NCs). However, it is unknown whether this is predictive of affect experienced in daily life and whether ER strategies are used less frequently and effectively by individuals with psychosis in daily life. Individuals with psychosis and current delusions (PDs; n = 71) and NCs (n = 42) completed questionnaires of habitual ER and experience sampling over 6 consecutive days, in which they reported 10 times a day on the presence of negative and positive affect and deployment of ER strategies (reappraisal, acceptance, awareness, suppression, rumination, distraction, and social sharing). Effectiveness of strategy use was operationalized by examining successive differences in positive and negative affect. Multilevel regression analyses were conducted. Questionnaires of habitual ER were largely predictive of affect in daily life. There was indication of a more frequent use of putatively maladaptive strategies but either no differences in individual adaptive strategies or even a more frequent use (reappraisal) in PDs compared to NCs. Several ER strategies (e.g., reappraisal, rumination) proved effective in reducing negative affect by the next prompt, independent of group, but suppression was effective in only PDs and acceptance had unfavorable effects in both groups. Thus, PDs demonstrated an increased use of ER strategies in daily life, of which the majority helped them to reduce negative affect. This indicates that their increased levels of negative affect are not explicable by difficulties in deploying explicit ER strategies. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Fostering coping as a mechanism of symptom change in cognitive behavioural therapy for psychosis.

INTRODUCTION: Cognitive behavioural therapy for psychosis (CBTp) has been repeatedly shown to ameliorate psychotic symptoms. However, so far we have little understanding of the mechanisms of change in CBTp. In this study, we tested whether improved cognitive and behavioural efforts to manage taxing external or internal demands (=coping) constitute a mechanism of change in CBTp. METHODS: Using data from a published trial for a secondary analysis, we tested whether the continuous symptomatic improvement of patients (n = 57) who received up to 45 sessions of CBTp and completed weekly self-assessments of symptoms (suspiciousness, individualised positive and negative symptoms, and individualised symptoms of depression) was mediated by preceding improvement in self-assessed coping using multilevel analysis. A reverse model in which symptom improvement predicted improved coping was also tested. RESULTS: Continuous improvement in suspiciousness, negative symptoms, and depression over the course of CBTp was preceded by improvement in coping. Improvement in suspiciousness or positive symptoms did not predict subsequent improvement in coping, whereas improvement in negative symptoms and depression predicted subsequent improvement in coping. CONCLUSION: Coping constitutes a mechanism of change, albeit to a different extent for different symptom clusters. Further research needs to explore how best to utilise this mechanism and optimise its integration with other active ingredients of CBTp to maximise therapeutic gain.

Awareness and rumination moderate the affective pathway to paranoia in daily life.

Numerous cross-sectional studies found psychosis to be associated with less awareness of emotions, a decreased use of adaptive (e.g. reappraisal) and an increased use of maladaptive emotion regulation (ER) strategies (e.g. suppression). In this study, we tested whether state levels of emotion awareness and momentary use of specific ER strategies moderate the link between negative affect at one timepoint (t-1) and paranoia at the next timepoint (t) in a six-day experience sampling study. Individuals with psychotic disorders (n = 71) reported on the presence of paranoia, negative affect, emotion awareness and the use of six ER strategies (reappraisal, acceptance, social sharing, distraction, suppression and rumination) ten times per day. Multilevel regression analysis revealed that higher awareness at t-1 reduced the association of negative affect at t-1 and paranoia at t, whereas rumination had an opposite, amplifying moderation effect. Our results provide novel insight into the conditions under which negative affect translates into delusional beliefs. The finding that emotion awareness and rumination have a relevant role corresponds with current psychological conceptualisations of psychosis and with the attempt to treat delusions by focusing on reducing ruminative thoughts. To investigate the causal effect, treatment trials with a focus on enhancing these components of emotion regulation are needed.

The relevance of cognitive emotion regulation to psychotic symptoms - A systematic review and meta-analysis.

Numerous studies emphasise the pivotal role of negative affect in the formation and maintenance of positive symptoms, which moves emotion regulation (ER) as a contributing factor into focus. We systematically reviewed and meta-analysed case-control studies reporting cross-sectional, correlative and experimental data of ER strategies in patients with psychotic disorders. In total, 42 studies were eligible, providing data for 2498 subjects and 3381 healthy controls. Questionnaire-based cross-sectional data (k=39) indicated strongest effects for rumination (g=-0,67 [-0,85 to -0,48]), self-blaming (g=-0,56; [-0,76 to -0,37]) and distraction (g=0,55 [0,11 to 0,98]). Suppression was more frequently (g=-0,36 [-0,56 to -0,16]) and cognitive reappraisal less frequently used (g=0,41 [0,28 to 0,55]), but heterogeneity was high. Correlative data (k=6) supported the assumption of an association between maladaptive strategies and positive symptoms (r=0,34 [0,22 to 0,44]). Less evidence of group differences was found in the experimental studies (k=3). The findings support the notion that ER is markedly impaired in patients with psychotic disorders. However, future research will need to further clarify the extent to which difficulties continue to exist after controlling for context and emotion intensity. The large effects for rumination and self-blaming point to promising treatment targets but also raise questions concerning the specifity of findings.

Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies.

BACKGROUND: Stressful life events and maltreatment have traditionally been considered crucial in the development of conversion (functional neurological) disorder, but the evidence underpinning this association is not clear. We aimed to assess the association between stressors and functional neurological disorder. METHODS: We systematically reviewed controlled studies reporting stressors occurring in childhood or adulthood, such as stressful life events and maltreatment (including sexual, physical abuse, and emotional neglect) and functional neurological disorder. We did a meta-analysis, with assessments of methodology, sources of bias, and sensitivity analyses. FINDINGS: 34 case-control studies, with 1405 patients, were eligible. Studies were of moderate-to-low quality. The frequency of childhood and adulthood stressors was increased in cases compared with controls. Odds ratios (OR) were higher for emotional neglect in childhood (49% for cases vs 20% for controls; OR 5·6, 95% CI 2·4-13·1) compared with sexual abuse (24% vs 10%; 3·3, 2·2-4·8) or physical abuse (30% vs 12%; 3·9, 2·2-7·2). An association with stressful life events preceding onset (OR 2·8, 95% CI 1·4-6·0) was stronger in studies with better methods (interviews; 4·3, 1·4-13·2). Heterogeneity was significant between studies (I2 21·1-90·7%). 13 studies that specifically ascertained that the participants had not had either severe life events or any subtype of maltreatment all found a proportion of patients with functional neurological disorder reporting no stressor. INTERPRETATION: Stressful life events and maltreatment are substantially more common in people with functional neurological disorder than in healthy controls and patient controls. Emotional neglect had a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This outcome supports changes to diagnostic criteria in DSM-5; stressors, although relevant to the cause in many patients, are not a core diagnostic feature. This result has implications for ICD-11. FUNDING: None.

Attention and sensation in functional motor disorder.

Functional motor disorder (FMD), also called psychogenic motor disorder or conversion disorder, describes impairments of motor function where there is no evidence of organic disease. The diagnosis is usually confirmed by positive clinical signs, such as Hoover's sign, in which normal power returns when attention is diverted away from the affected limb. This suggests that selective attention is an important determinant of these functional symptoms. The present study is the first specifically to explore the shifting of spatial attention in relation to the side of FMD. We tested 14 patients with unilateral functional upper limb weakness on three tasks requiring detection of visual targets close to the affected or unaffected hand, or touches to the hand itself. Targets were preceded by central cues promoting voluntary shifts of attention, or peripheral cues promoting automatic shifts. We observed a reduced response to visual and/or tactile targets on the affected side in around half of the patients, by comparison with age-matched controls, indicating that some degree of detection cost often accompanies FMD. Additionally, although the patient group showed normal cueing effects on the visual tasks, they had a unilateral absence of cueing effect on the affected side in the tactile task. Consideration of the data in the context of recent theory suggests that the abnormality may be not in the shifting of attention itself, but rather in the consequences of attending to the affected side. Specifically, the expected cueing effects may be absent on the affected side, because attention to a functionally weak limb increases the perception of the symptom, including any reduced sensory response. This preliminary research suggests promising new lines of investigation into the role of attention, and particularly somatic attention, in FMD.

Transcranial magnetic stimulation as a treatment for functional (psychogenic) upper limb weakness.

OBJECTIVE: There has been a recent resurgence of interest in physical treatments for functional motor disorders (FMD) including Transcranial Magnetic Stimulation (TMS). This pilot study aimed to test the effectiveness of a single session of motor cortex TMS as a treatment for functional upper limb weakness. METHODS: Ten subjects with a diagnosis of functional upper limb weakness were randomised to immediate (n=7) or delayed (3months) (n=3) TMS treatment. Median age was 35 (range 23-52) and median symptom duration was 2.3years (range 5months - 20years). 46-70 single pulses were applied to the motor cortex at 120-150% motor threshold. We used a verbal protocol designed to standardized the effects of suggestion. Primary outcome measures were self-reported symptom severity, grip strength and tapping frequency immediately after treatment, and symptom severity and disability (SF-12 and Modified Rankin Scale (MRS)) after 3months. RESULTS: There was a small significant reduction in symptom severity immediately after treatment, but no improvement in grip strength or tapping frequency and no change in symptom severity, SF-12 or MRS 3months after treatment. Small numbers precluded comparison of immediate treatment with delayed treatment. Four of eight subjects responding to three-month follow-up reported late-onset adverse effects. CONCLUSION: This pilot study suggests limited benefits for TMS as a one-off non-neuromodulatory treatment for stable chronic outpatients. TMS may still have a role alongside more intensive multidisciplinary therapy input, or in patients with severe deficits where the possibility of normal movement can be hard to demonstrate. TRIAL REGISTRATION: NCT02102906.

Functional neurological disorders: mechanisms and treatment.

Functional neurological disorders are common problems in neurologic practice. In the past decade there has been an increasing interest in this group of disorders both from a clinical as well as research point of view. In this review, we highlight some of the most salient and exciting publications from recent years focusing especially on new findings illuminating mechanism and studies examining treatment.

Differences in illness perceptions between patients with non-epileptic seizures and functional limb weakness.

OBJECTIVES: Illness perceptions play an important role in the onset and maintenance of symptoms in functional neurological symptom disorder (conversion disorder). There has, however, been little work examining differences between subtypes of this disorder. We therefore aimed to compare illness perceptions of patients with non-epileptic seizures (NES) and those with functional weakness (FW) with matching neurological disease controls to examine their specificity. METHODS: The Illness Perception Questionnaire Revised (IPQ-R) was completed by patients with functional limb weakness, non-epileptic seizures and patients with neurological disease causing limb weakness and epilepsy in two separate case control studies. RESULTS: Patients with FW (n=107), NES (=40), Epilepsy (n=34) and neurological disease causing limb weakness (NDLW) (n=46) were included in the analysis. Both FW and NES patients reported a low level of personal control, understanding of their symptoms and a tendency to reject a psychological causation of their symptoms. However NES patients rejected psychological causes less strongly than FW patients (P<.01). Patients with NES were also more likely to consider their treatment to be more effective (P<.01). None of these differences appeared in a similar comparison between patients with epilepsy and patients with NDLW. CONCLUSION: Although patients with NES tended, as a group, to reject psychological factors as relevant to their symptoms, they did so less strongly than patients with functional limb weakness in these cohorts. This has implications for both the way in which these symptoms are grouped together but also the way in which treatment is approached.