A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study.

BACKGROUND: Psychogenic nonepileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism is far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies. OBJECTIVE: To To present a within-group posttreatment vs pretreatment study representing the retrospective clinical results of an integrative psychotherapy model. METHODS: We present the clinical results of 22 patients with PNES diagnosed in an epilepsy center and treated in our neuropsychiatry clinic using an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques, and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific. RESULTS: By the end of treatment, 36% of patients had become seizure free and a further 54% achieved a major seizure reduction (reduction of more than 70%). Seventy-two percent of patients kept at least 70% seizure reduction at follow-up. Global Assessment of Functioning scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow-up. In addition, we present 3 case descriptions that emphasize the individualized nature of psychotherapeutic decisions. CONCLUSIONS: Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.

Theta-alpha oscillations characterize emotional subregion in the human ventral subthalamic nucleus.

BACKGROUND: Therapeutic outcomes of STN-DBS for movement and psychiatric disorders depend on electrode location within the STN. Electrophysiological and functional mapping of the STN has progressed considerably in the past years, identifying beta-band oscillatory activity in the dorsal STN as a motor biomarker. It also has been suggested that STN theta-alpha oscillations, involved in impulse control and action inhibition, have a ventral source. However, STN local field potential mapping of motor, associative, and limbic areas is often limited by poor spatial resolution. OBJECTIVES: Providing a high-resolution electrophysiological map of the motor, associative and limbic anatomical sub-areas of the subthalamic nucleus. METHODS: We have analyzed high-spatial-resolution STN microelectrode electrophysiology recordings of PD patients (n = 303) that underwent DBS surgery. The patients' STN intraoperative recordings of spiking activity (933 electrode trajectories) were combined with their imaging data (n = 83 patients, 151 trajectories). RESULTS: We found a high theta-alpha (7-10 Hz) oscillatory area, located near the STN ventromedial border in 29% of the PD patients. Theta-alpha activity in this area has higher power and lower central frequency in comparison to theta-alpha activity in more dorsal subthalamic areas. When projected on the DISTAL functional atlas, the theta-alpha oscillatory area overlaps with the STN limbic subarea. CONCLUSIONS: We suggest that theta-alpha oscillations can serve as an electrophysiological marker for the ventral subthalamic nucleus limbic subarea. Therefore, theta-alpha oscillations can guide optimal electrode placement in neuropsychiatric STN-DBS procedures and provide a reliable biomarker input for future closed-loop DBS device. © 2019 International Parkinson and Movement Disorder Society.

Memory and motor control in patients with psychogenic nonepileptic seizures.

Psychogenic nonepileptic seizures (PNES) are of the most elusive phenomena in epileptology. Patients with PNES present episodes resembling epileptic seizures in their semiology yet lacking the underlying epileptic brain activity. These episodes are assumed to be related to psychological distress from past trauma, yet the underlying mechanism of this manifestation is still unknown. Using resting-state functional magnetic resonance imaging (fMRI), we investigated functional connectivity changes within and between large-scale brain networks in 9 patients with PNES, compared with a group of 13 age- and gender-matched healthy controls. Functional magnetic resonance imaging analyses identified functional connectivity disturbances between the medial temporal lobe (MTL) and the sensorimotor cortex and between the MTL and ventral attention networks in patients with PNES. Within network connectivity reduction was found within the visual network. Our findings suggest that PNES relate to changes in connectivity in between areas that are involved in memory processing and motor activity and attention control. These results may shed new light on the way by which traumatic memories may relate to PNES.

[DEEP BRAIN STIMULATION FOR OBSESSIVE COMPULSIVE DISORDER: CASE REPORT OF THE FIRST OCD PATIENT IN ISRAEL].

INTRODUCTION: Treatment-resistant obsessive-compulsive disorder (OCD) is considered a severe psychiatric disorder that causes severe functional decline. In the past, these patients were treated by selective ablation of neuronal pathways related to the pathophysiology of OCD. Deep brain stimulation is an effective and safe treatment alternative that enables reversible changes in neural circuits and reduces OCD symptoms. In this paper we present the outcome of a treatment-resistant OCD patient who underwent deep brain stimulation procedure for the first time in Israel. The patient has achieved a significant decline in OCD symptoms as well as improvement in personal and social functioning. The discussion focuses on methods to implement deep brain stimulation for OCD patients in Israel.

Subthalamic theta activity: a novel human subcortical biomarker for obsessive compulsive disorder.

Obsessive-compulsive disorder (OCD) is a common and serious psychiatric disorder. Although subthalamic nucleus deep brain stimulation (DBS) has been studied as a treatment for OCD patients the underlying mechanism of this treatment and the optimal method of stimulation are unknown. To study the neural basis of subthalamic nucleus DBS in OCD patients we used a novel, implantable DBS system with long-term local field potential sensing capability. We focus our analysis on two patients with OCD who experienced severe treatment-resistant symptoms and were implanted with subthalamic nucleus DBS systems. We studied them for a year at rest and during provocation of OCD symptoms (46 recording sessions) and compared them to four Parkinson's disease (PD) patients implanted with subthalamic nucleus DBS systems (69 recording sessions). We show that the dorsal (motor) area of the subthalamic nucleus in OCD patients displays a beta (25-35 Hz) oscillatory activity similar to PD patients whereas the ventral (limbic-cognitive) area of the subthalamic nucleus displays distinct theta (6.5-8 Hz) oscillatory activity only in OCD patients. The subthalamic nucleus theta oscillatory activity decreases with provocation of OCD symptoms and is inversely correlated with symptoms severity over time. We conclude that beta oscillations at the dorsal subthalamic nucleus in OCD patients challenge their pathophysiologic association with movement disorders. Furthermore, theta oscillations at the ventral subthalamic nucleus in OCD patients suggest a new physiological target for OCD therapy as well as a promising input signal for future emotional-cognitive closed-loop DBS.

Long-term outcome of early interventions to prevent posttraumatic stress disorder.

BACKGROUND: Failing to prevent posttraumatic stress disorder (PTSD) has major clinical and public health consequences. This work evaluates the 3-year outcome of offering early interventions to survivors with acute PTSD. METHODS: Adults admitted consecutively to the hospital with acute DSM-IV PTSD were randomized, between June 2003 and October 2007, to 12 weeks of prolonged exposure (n = 63) or cognitive therapy (n = 40) or concealed SSRI (escitalopram; n = 23) versus placebo (n = 23). Eighty-two participants who declined treatment were followed as well. Treatment started 1 month after the traumatic event, and participants were reassessed 5 and 36 months later. Assessors were blinded to treatment allocation and acceptance. The Clinician-Administered PTSD Scale (CAPS) evaluated PTSD and PTSD symptoms. Self-reported symptoms, general functioning, and employment status were secondary outcomes. Participants lost to follow-up were missing completely at random. RESULTS: Prolonged exposure and cognitive therapy significantly reduced PTSD and PTSD symptoms between 1 and 5 months (mean CAPS total scores [95% CI] at 1 month: prolonged exposure = 73.59 [68.21-78.96] and cognitive therapy = 71.78 [66.92-78.93]; mean CAPS total scores [95% CI] at 5 months: prolonged exposure = 28.59 [21.89-35.29] and cognitive therapy = 29.48 [21.32-37.95], P < .001), and their results remained stable. At 3 years, however, the study groups had similar levels of PTSD symptoms (mean CAPS total scores [95% CI]: prolonged exposure = 31.51 [20.25-42.78]; cognitive therapy = 32.08 [20.74-43.42]; SSRI = 34.31 [16.54-52.07]; placebo = 32.13 [20.15-44.12]; and no intervention = 30.59 [19.40-41.78]), similar prevalence of PTSD (28.6%-46.2%), and similar secondary outcomes. CONCLUSION: Early prolonged exposure and cognitive therapy accelerated the recovery from acute PTSD. Their effect remained stable, however, without reducing the 3-year prevalence of the disorder. The lingering prevalence of PTSD, despite efficient interventions, illustrates a nonremitting, treatment-refractory subset of survivors and outlines a major clinical and public health challenge. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00146900.

Social relationship satisfaction and PTSD: which is the chicken and which is the egg?

BACKGROUND: Impaired social relationships are linked with higher levels of posttraumatic stress disorder (PTSD), but the association's underlying dynamics are unknown. PTSD may impair social relationships, and, vice versa, poorer relationship quality may interfere with the recovery from PTSD. OBJECTIVE: This work longitudinally evaluates the simultaneous progression of PTSD symptoms and social relationship satisfaction (SRS) in a large cohort of recent trauma survivors. It also explores the effect of cognitive behavior therapy (CBT) on the association between the two. METHOD: Consecutive emergency department trauma admissions with qualifying PTSD symptoms (n=501) were assessed 3 weeks and 5 months after trauma admission. The World Health Organization Quality of Life evaluated SRS and the Clinician Administered PTSD Scale evaluated PTSD symptom severity. Ninety-eight survivors received CBT between measurement sessions. We used Structural Equation Modeling to evaluate cross-lagged effects between the SRS and PTSD symptoms. RESULTS: The cross-lagged effect of SRS on PTSD was statistically significant (ß=-0.12, p=0.01) among survivors who did not receive treatment whilst the effect of PTDS on SRS was nil (ß=-0.02, p=0.67). Both relationships were non-significant among survivors who received CBT. DISCUSSION: SRS and PTSD are highly associated, and this study shows that changes in SRS in the early aftermath of traumatic events contribute to changes in PTSD, rather than vice versa. SRS impacts natural recovery, but not effective treatment. This study suggests that being satisfied with one's relationships might be considered as an important factor in natural recovery from trauma, as well as in intervention.

Head injury and loss of consciousness raise the likelihood of developing and maintaining PTSD symptoms.

Mild traumatic brain injury has been associated with higher prevalence of posttraumatic stress disorder (PTSD). The extent to which head injury or loss of consciousness predicts PTSD is unknown. To evaluate the contribution of head injury and loss of consciousness to the occurrence of PTSD, we made a longitudinal evaluation of 1,260 road accident survivors admitted to the emergency department with head injury (n = 287), head injury and loss of consciousness (n = 115), or neither (n = 858). A telephone-administered posttraumatic symptoms scale inferred PTSD and quantified PTSD symptoms at 10 days and 8 months after admission. The study groups had similar heart rate, blood pressure, and pain levels in the emergency department. Survivors with loss of consciousness and head injury had higher prevalence of PTSD and higher levels of PTSD symptoms, suggesting that patients with head injury and loss of consciousness reported in the emergency department are at higher risk for PTSD.

Early PTSD symptom trajectories: persistence, recovery, and response to treatment: results from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS).

CONTEXT: Uncovering heterogeneities in the progression of early PTSD symptoms can improve our understanding of the disorder's pathogenesis and prophylaxis. OBJECTIVES: To describe discrete symptom trajectories and examine their relevance for preventive interventions. DESIGN: Latent Growth Mixture Modeling (LGMM) of data from a randomized controlled study of early treatment. LGMM identifies latent longitudinal trajectories by exploring discrete mixture distributions underlying observable data. SETTING: Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity. PARTICIPANTS: Adult survivors of potentially traumatic events consecutively admitted to the hospital's emergency department (ED) were assessed ten days and one-, five-, nine- and fifteen months after ED admission. Participants with data at ten days and at least two additional assessments (n = 957) were included; 125 received cognitive behavioral therapy (CBT) between one and nine months. APPROACH: We used LGMM to identify latent parameters of symptom progression and tested the effect of CBT on these parameters. CBT consisted of 12 weekly sessions of either cognitive therapy (n = 41) or prolonged exposure (PE, n = 49), starting 29.8±5.7 days after ED admission, or delayed PE (n = 35) starting at 151.8±42.4 days. CBT effectively reduced PTSD symptoms in the entire sample. MAIN OUTCOME MEASURE: Latent trajectories of PTSD symptoms; effects of CBT on these trajectories. RESULTS: THREE TRAJECTORIES WERE IDENTIFIED: Rapid Remitting (rapid decrease in symptoms from 1- to 5-months; 56% of the sample), Slow Remitting (progressive decrease in symptoms over 15 months; 27%) and Non-Remitting (persistently elevated symptoms; 17%). CBT accelerated the recovery of the Slow Remitting class but did not affect the other classes. CONCLUSIONS: The early course of PTSD symptoms is characterized by distinct and diverging response patterns that are centrally relevant to understanding the disorder and preventing its occurrence. Studies of the pathogenesis of PTSD may benefit from using clustered symptom trajectories as their dependent variables.