Mood symptoms in cervical dystonia: Relationship with motor symptoms and quality of life.

Background: Cervical dystonia (CD) has a high prevalence of anxiety and depression. The relationship between motor severity, mood symptoms and QoL is unclear and how to adequately assess these is also unknown. Instruments like the BAI, BDI and HADS are often used but items within these relating to somatic symptoms might influence the results. Methods: Patients with idiopathic cervical dystonia (CD) were included. The BAI, BDI, HADS, CIDP58 and TWSTRS2- severity score were used for assessment of motor, mood and QoL symptoms. Pearson's correlations between motor and non-motor symptom scores were assessed. The psychometric properties of the psychiatric tools were measured and principal component analysis performed after identifying items that could correspond to somatic symptoms. Results: 201 participants were included. 42% of participants had either significant depression or anxiety symptoms or both when measured by BAI and BDI and 51% of patients met criteria on HADS. HADS-A and HADS-D, BAI and BDI were poorly correlated with TWSTRS2-S. The HADS-A and HADS-D both showed strong correlation with the sleep subdomain of CDIP58. Psychometric and principal component analysis on 149/201 participants did not reveal factor loadings consistent with the a priori somatic groupings. However mean scores were higher for somatic items. Conclusion: A good score on the CDIP58, a commonly used tool, does not indicate mild disease severity or minimal mood symptoms. Minimal motor symptoms, similarly, also does not imply a positive QoL. Clinicians should be mindful on ideal methods for performing a holistic assessment of CD patients. This likely warrants a combination of motor, QoL and mood assessment tools.

Longitudinal Follow-Up of Mood in Cervical Dystonia and Influence on Age at Onset.

Background: Anxiety and depression are highly prevalent conditions in cervical dystonia and considered intrinsic to the disease mechanism. Psychiatric symptoms do not appear to be influenced by botulinum toxin therapy. Studies focusing on changes in mood disorder during the course of the disease are limited in this chronic, lifelong disorder. Objective: To assess the longitudinal prevalence of mood disorder, pain, and quality of life in patients with cervical dystonia attending a botulinum toxin clinic. Methods: Patients involved in phase I of our study were invited to be involved in reassessment using the Beck Depression Inventory, Second Revision; Beck Anxiety Index; Cervical Dystonia Impact Profile-58 (CDIP-58); and the Toronto Western Spasmodic Torticollis Rating Scale-2 Pain Scale (TWSTRS2-Pain). Results: A total of 53 participants took part after a mean study interval duration of 24 months. There were no significant differences between the 2 study time points in the prevalence of anxiety (P = 0.2919) and depressive symptoms (P = 0.5). Self-reported quality of life by CDIP-58 (P = 0.96) and pain by TWSTRS2-Pain (P = 0.9321) were unchanged. Men and women with significant symptoms of mood disorder had an earlier age of onset of cervical dystonia (P = 0.008). Conclusion: Anxiety and depressive symptoms persist in cervical dystonia, seem to be unrelated to pain severity, and need to be specifically targeted to improve quality of life. The relationship between mood disorder and age of onset suggest that mood disorder may be part of the disease pathophysiology.

Reliability of DNMSQuest as a Screening Tool for Mood Disorders in Cervical Dystonia.

BACKGROUND: The high prevalence of mood disorders in cervical dystonia, often unaddressed in botulinum toxin clinics, is a major factor in impaired quality of life. There is a clear need for a brief screening method for identifying these disorders; the Dystonia non-motor symptoms questionnaire (DNMSQuest) has been proposed as such. OBJECTIVE: We aimed to assess the practical utility of the DNMSQuest and compare it with validated rating scales for anxiety, depression and quality of life. METHODS: In 88 patients with cervical dystonia, we compared results from the DNMSQuest with mood rating scales [Beck Anxiety Inventory (BAI), Beck Depression Index (BDI-II) and Hospital Anxiety and Depression Scale (HADS)], quality of life measures [European Quality of Life (EQOL) and European Quality of Life Visual Analogue Scale (EQOLVAS)] and with assessments of dystonia severity [Cervical Dystonia Impact Profile-58 (CDIP58) and Toronto Western Rating Scale for Spasmodic Torticollis (TWSTRS)]. RESULTS: Using a cut off score on the DNMSQuest of 5, we noted that DNMSQuest had a sensitivity of 85% for detecting anxiety and depression using the BAI and BDI-II, and 76% and 78% for anxiety and depression respectively using the HADS. The DNMSQuest correlated strongly with BAI (ρ = 0.715), BDI-II (ρ = 0.658), HADS-Anxiety (ρ = 0.616), HADS-Depression (ρ = 0.706), EQOL (ρ = 0.653) and CDIP-58 (ρ = 0.665). CONCLUSION: The DNMSQuest is a brief, sensitive and non-specific instrument for identifying patients that warrant further review for anxiety and depression and can easily be implemented in a neurologist-run botulinum toxin clinic.

Non-motor features of cervical dystonia: Cognition, social cognition, psychological distress and quality of life.

INTRODUCTION: Non-motor features of cervical dystonia (CD) have been identified, including depression, anxiety, and neuropsychological deficits. The aims were: to provide a clinical neuropsychological profile of CD patients with specific focus on social cognition; assess levels of psychological distress; and investigate the relationship between non-motor features of CD, including cognitive functioning, psychological distress, CD severity, pain, and health-related quality of life (HR-QoL). METHODS: A multi-domain neuropsychological assessment battery was administered to 46 participants with CD, examining cognitive and social cognitive domains. Clinical data on dystonia severity, pain, psychological distress and HR-QoL were collected. RESULTS: The majority of participants with CD performed within the average range across most tests of cognition. Scores were significantly lower than standardized norms in social cognition, processing speed, and aspects of memory. High levels of anxiety (Hospital Anxiety and Depression Scale [HADS-A] ≥ 11, 30%) and depression (HADS-D ≥ 11; 29%) were observed. Psychological distress, CD severity, pain and HR-QoL were not significantly associated with neuropsychological functioning after controlling for multiple comparisons. Low HR-QoL was associated with higher levels of pain and psychological distress, but not severity of motor symptoms. CONCLUSION: Results indicate that psychological distress and deficits in cognitive and social cognitive functioning are likely distinct features of CD. While motor symptoms do not appear to impact HR-QoL, pain and psychological distress were associated with low HR-QoL. Findings highlight the importance of addressing non-motor symptoms in the treatment of CD.

Trust the Patient Not the Doctor: The Determinants of Quality of Life in Cervical Dystonia.

Background: Mood disorder is common in cervical dystonia and can impact on quality of life. It often precedes the onset of cervical dystonia and does not improve with botulinum toxin therapy. Objective: To assess health-related quality of life in relation to mood disorder and measures of severity, disability and pain, in cervical dystonia patients receiving botulinum toxin therapy. Methods: In a single-center, University Hospital movement disorders clinic, we conducted a comprehensive, cross-sectional study of disease severity, non-motor symptoms, mood and health-related quality of life in patients with cervical dystonia receiving botulinum toxin therapy using TWSTRS-2 for pain, severity and disability; Beck Anxiety Inventory and Beck Depression Inventory. We assessed all variables in relation to health-related quality of life assessed by Cervical Dystonia Impact Profile-58 and the Euro-QoL Utility Index. Results: In 201 patients (136 women), mean age 61.5 years, significant determinants of impaired health related quality of life were: being a woman, reporting a history of anxiety or depression, prevalent pain, disability, anxiety and/or depression but not physician-assessed disease severity. Conclusion: Patient-reported measures of pain, disability and, most markedly, mood disorder, are significant factors affecting quality of life; these were totally unrelated to the neurologist-rated measure of disease severity. Mood disorders, the predominant predictor of quality of life, were not addressed in the botulinum toxin clinic.

Mood disorder affects age at onset of adult-onset cervical dystonia.

INTRODUCTION: Mood disorder is common in cervical dystonia, affects quality of life and may precede the onset of the dystonia. There is controversy as to whether mood disorder is part of the primary process or secondary to the disability.We assessed the characteristics of cervical dystonia patients in relation to a past history of mood disorder. METHODS: At a University Hospital clinic, in all consenting patients with cervical dystonia, we uniformly collected demographic data, medical history, and prospectively, measures of prevalent mood disorder. RESULTS: In 193 patients (128 women and 65 men) mean age at onset was 43.9 years and mean duration of cervical dystonia was 17.5 years. Men had earlier age at onset of cervical dystonia than women (p = 0.0037). A history of a mood disorder was reported in 53/128 (41%) women with a significantly earlier median age at onset of cervical dystonia (42 years) than 75/128 (59%) women with no history of mood disorder (48 years) (p = 0.005); 33 (26%) women with mood disorder prior to dystonia also had an earlier age at onset of dystonia than the 75 without such a history (p = 0.0154). A history of mood disorder was more common in women (41%) than men (31%); 54/128 (42%) women and 21/65 (32%) men had current mood disorder symptoms. CONCLUSIONS: In our cervical dystonia clinic population significant differences in the age at onset in women with, and without, a history of mood disorder strongly indicates that anxiety and depression are primary non-motor (and premotor) symptoms of cervical dystonia.

Social cognition in cervical dystonia: A case-control study.

BACKGROUND: Although considered a motor disorder, adult onset isolated focal dystonia has many non-motor symptoms. There is a paucity of neuropsychological research on cognitive processing in adult onset focal dystonia. METHODS: We employed a battery of clinical and cognitive assessments, including basic and complex social cognition, and assessed 46 patients with adult-onset cervical dystonia, compared to 46 age-, sex-, education-, and premorbid IQ-matched healthy controls. RESULTS: Significant between-group differences were observed in relation to measures of memory encoding, recall and recognition, as well as multimodal measures of basic Social Cognition (emotion recognition: face and prosody), but not complex Social Cognition (mentalising). There were no deficits observed in multimodal measures of executive function. Controlling for mood did not affect performance. CONCLUSION: In this multi-dimensional assessment of cognition in cervical dystonia, we report deficits in memory encoding, and in social cognition. Further investigation of social cognitive processes, memory, and sustained attention are required. Longitudinal studies are also needed to further delineate the role of psychological distress on cognitive outcomes and document the cognitive profile over time.