Illness perceptions, experiences of stigma and engagement in functional neurological disorder (FND): exploring the role of multidisciplinary group education sessions.

Background: A critical first step in managing functional neurological disorder (FND) is a positive diagnosis and clear explanation using an understandable illness model. Multidisciplinary group education sessions are one way to achieve this, with some evidence they improve understanding, confidence in diagnosis and outcomes with further treatment. In many conditions, illness perceptions and stigma affect distress, functioning, quality of life and engagement. Exploring relationships between these factors could lead to deeper understanding of the impact of education. Methods: Questionnaires assessing illness perceptions, quality of life, mood, anxiety, comorbidities, treatment engagement and stigma (both experienced and anticipated) were completed before, immediately and 1 month after a multidisciplinary online group education session for FND at a regional neurosciences centre. Free-text data on causal attributions and needs were also collected. Results: 166 patients attended online education sessions from January 2022 to July 2023; 61 (37%) completed presession surveys, 42 (25%) completed postsession and 35 (21%) completed 1 month postsession surveys. Patients reported multiple comorbidities, poor quality of life, functioning and high levels of stigma. Illness perception scores indicated FND as threatening, mysterious and unpredictable, with low personal or treatment control over symptoms. Illness coherence/understanding (mean difference 2.27, p<0.01, 95% CI 1.22 to 4.23) and engagement (mean difference 2.42, p<0.01, 95% CI 0.46 to 4.36) increased after the session. There were no significant changes in stigma, distress, sense of control or anticipated discrimination. Free-text analysis revealed stress and trauma as the most common causal attributions, followed by physical illnesses. Patients requested personalised formulations, practical disability advice, help with explaining the condition to others (eg, employers), peer support and treatment. Conclusion: Multidisciplinary group FND education sessions potentially improve patient understanding and engagement. Clinicians should consider the possible benefits of personalised formulations and linking to practical and peer support. Further work assessing illness perceptions is needed, such as adapting measures for FND.

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.

Cross-sectional evaluation of health resource use in patients with functional neurological disorders referred to a tertiary neuroscience centre.

Introduction: Functional neurological disorder (FND) is a common cause of referral to neurology services. FND has been shown to lead to significant healthcare resource use and is associated with significant disability, comorbidity and distress. This leads to substantial direct, indirect and intangible costs to the patient and society. Methods: We recruited consecutive patients with FND referred to a tertiary FND specialist clinic. We assessed health and social care resource use in the 6 months preceding their consultation through a modified version of the Client Service Receipt Inventory in the form of a postal questionnaire. The total cost was estimated by combining the number and frequency of health resource use with standard national unit costs. We also assessed indirect costs such as informal care and loss of income. Results: We collected data on 118 subjects. Patients with comorbid anxiety or depression had higher costs in the preceding 6 months, as did patients who had a longer duration of FND symptoms. Indirect costs were higher than the already substantial direct costs and a large proportion of patients with FND were receiving government support. Conclusion: This study highlights the high cost of FND to both patients and health systems. Adequate reform of the patient pathway and reorganisation of services to make diagnoses and initiate treatment more quickly would likely reduce these costs.

Impaired cardiac modulation in patients with functional seizures: Results from a face intensity judgment task.

OBJECTIVE: Although interoceptive abnormality in patients with functional seizure (FSs) has been demonstrated using explicit tasks, implicit measurements of interoception such as the effect of interoception on perceptual brain processes have not been investigated. It has been shown that perception is normally modulated by interoceptive signals related to the different phases (systole vs diastole) of the cardiac cycle (cardiac modulation effect). Given our previous findings using explicit measures of interoception, we hypothesized that cardiac modulation would be impaired in FSs. METHODS: Thirty-two patients with FSs and 30 age- and sex-matched non-clinical individuals conducted a face intensity judgment task, in which their intensity rating when fearful or neutral faces was presented was compared between systolic and diastolic phases. They also conducted the heartbeat discrimination task as a measure of their capacity to integrate both interoceptive and exteroceptive information. RESULTS: Patients with FSs had impaired cardiac modulation of the perception of neutral faces (corrected p = .044). Individual differences in the heartbeat discrimination task predicted the degree to which cardiac modulation occurred across the whole group (p = .028). This cardiac modulation effect was significantly associated with seizure severity (p = .021). Regardless of cardiac phase, patients rated fearful facial expressions as less intense compared to control participants (p = .006). SIGNIFICANCE: These findings highlight impaired implicit cardiac modulation effects in patients with FSs. This reflects interoceptive dysfunction in patients with FSs, and an inability of the brain to integrate interoceptive signaling with perceptual processing. This may have implications for our understanding of the pathophysiology in FSs and inform novel diagnostic approaches.

MODIFI: protocol for randomised feasibility study of eye-movement desensitisation and reprocessing therapy (EMDR) for functional neurological disorder (FND).

INTRODUCTION: Functional neurological disorder (FND) refers to an involuntary loss of control over and/or aberrant perception of the body. Common presenting symptoms are functional (non-epileptic) seizures, and functional motor disorder, for example, walking difficulties, weakness or tremor. Greater access to effective treatments would lead to reduced distress and disability; and reduce unnecessary healthcare costs.This study will examine eye-movement desensitisation and reprocessing therapy (EMDR) as a treatment for FND. EMDR is an evidence-based treatment for post-traumatic stress disorder (PTSD), but its use for other conditions is growing. An FND-specific EMDR protocol will be tested, and if the intervention proves feasible with promising clinical outcomes, progression to a substantive study could take place. METHODS AND ANALYSIS: Fifty adult patients diagnosed with FND will be recruited. It will be a single-blind randomised controlled trial with two arms: EMDR (plus standard neuropsychiatric care; NPC) and standard NPC. The two groups will be compared at baseline (T0), 3 months (T1), 6 months (T2) and 9 months (T3). Measures of feasibility include safety, recruitment, retention, treatment adherence and acceptability. Clinical outcome measures will assess health-related functioning/quality of life, ratings of FND symptoms and severity, depression, anxiety, PTSD, dissociation, service utilisation and other costs. Improvement and satisfaction ratings will also be assessed. Feasibility outcomes will be summarised using descriptive statistics. Exploratory analyses using (linear/logistic) mixed-effect models will examine the rate of change in the groups' clinical outcome measures across the four time-points.After the intervention period, a sample of participants, and clinicians, will be invited to attend semistructured interviews. The interviews will be analysed using reflexive thematic analysis. ETHICS AND DISSEMINATION: This study has been approved by the NHS West Midlands-Edgbaston Research Ethics Committee. Study findings will be published in open access peer-reviewed journals, presented at conferences, and communicated to participants and other relevant stakeholders. TRIAL REGISTRATION: NCT05455450 (www. CLINICALTRIALS: gov).

Feasibility randomised controlled trial of online group Acceptance and Commitment Therapy for Functional Cognitive Disorder (ACT4FCD).

INTRODUCTION: Functional cognitive disorder (FCD) is seen increasingly in clinics commissioned to assess cognitive disorders. Patients report frequent cognitive, especially memory, failures. The diagnosis can be made clinically, and unnecessary investigations avoided. While there is some evidence that psychological treatments can be helpful, they are not routinely available. Therefore, we have developed a brief psychological intervention using the principles of acceptance and commitment therapy (ACT) that can be delivered in groups and online. We are conducting a feasibility study to assess whether the intervention can be delivered within a randomised controlled trial. We aim to study the feasibility of recruitment, willingness to be randomised to intervention or control condition, adherence to the intervention, completion of outcome measures and acceptability of treatment. METHODS AND ANALYSIS: We aim to recruit 48 participants randomised 50:50 to either the ACT intervention and treatment as usual (TAU), or TAU alone. ACT will be provided to participants in the treatment arm following completion of baseline outcome measures. Completion of these outcome measures will be repeated at 8, 16 and 26 weeks. The measures will assess several domains including psychological flexibility, subjective cognitive symptoms, mood and anxiety, health-related quality of life and functioning, healthcare utilisation, and satisfaction with care and participant-rated improvement. Fifteen participants will be selected for in-depth qualitative interviews about their experiences of living with FCD and of the ACT intervention. ETHICS AND DISSEMINATION: The study received a favourable opinion from the South East Scotland Research Ethics Committee 02 on 30 September 2022 (REC reference: 22/SS/0059). HRA approval was received on 1 November 2022 (IRAS 313730). The results will be published in full in an open-access journal. TRIAL REGISTRATION NUMBER: ISRCTN12939037.

Hypermobility in patients with functional seizures: Toward a pathobiological understanding of complex conditions.

BACKGROUND: Functional seizures (FS), otherwise known as psychogenic nonepileptic seizures (PNES), are a common symptom presenting to neurology and epilepsy clinics. There is a pressing need for further research to understand the neurobiology of FS to develop mechanistically targeted treatments. Joint hypermobility is an expression of variation in connective tissue structure along a spectrum, and it has received increasing attention in functional neurological disorders, but there is lack of evidence of its relevance in FS. METHODS: In the present study, forty-two patients with FS and a non-clinical comparison group of 34 age/sex-matched controls were recruited. Joint hypermobility of all participants was quantified using the Beighton scale. RESULTS: In our sample, 24 (57%) patients with FS, and 7 (21%) of the comparison group met criteria for joint hypermobility (p = 0.002). Our statistical model revealed that patients with FS showed a significant degree of hypermobility compared to the comparison group (odds ratio = 11.1; Confidence interval: 2.1-78.0, p = 0.008), even after controlling age, sex, anxiety, and depression. CONCLUSION: We found a significant association between FS and joint hypermobility, which was independent of anxiety and depression.

What do patients prefer their functional seizures to be called, and what are their experiences of diagnosis? - A mixed methods investigation.

This study explored the preferred terms for functional seizures, and the experience of being diagnosed, from the patient's perspective. 39 patients in a neuropsychiatry service diagnosed with functional seizures completed an online survey to investigate preferences for, and offensiveness of, 11 common diagnostic terms used to describe functional seizures. Of these 39 patients, 13 consented to take part in a semistructured interview exploring the experience of receiving a diagnosis. Nonepileptic attack disorder (NEAD), functional seizures, functional nonepileptic attacks (FNEA), and dissociative seizures were ranked the highest preferred terms and did not significantly differ from one another. NEAD was the least offensive term, with functional seizures and FNEA following closely. Significant overlap in confidence intervals was found between the offensiveness of all terms. Terms that indicated a psychological origin were the least preferred and viewed as most offensive. Thematic analysis identified three main themes on the experience of being diagnosed: 'being heard and having a shared understanding', 'feeling alone', and 'sense of hope'. Patients favored diagnostic terms that facilitated and alleviated these themes on a personal basis; however, preferences differed across individuals. Our findings suggest that a range of terms have a similar level of preference and offense rating, with NEAD, functional seizures, and FNEA being the most favorable. Qualitative analysis indicates that a term and its accompanying explanation should facilitate shared acceptance and understanding, and several terms provide this. In combination with our previous study on healthy participants, we propose that one of the two terms researched are adopted by patients, health professionals, and the public: Functional nonepileptic attacks or Functional seizures.

Exploring educational integrated training posts in general practice: a phenomenological study of trainees' perspectives.

This study explores the experience of undertaking an educational integrated training post (ITP) in general practice. There are problems with General Practice (GP) recruitment and retention in the UK and worldwide. It is thought that integrated training programmes (ITPs) within GP training may offer a new and appealing way of training, which may address this problem. Health Education England North East (HEENE) has been running educational integrated training posts for over 5 years. Integrated training schemes such as this have been rarely studied and in particular the trainees' perspectives. In order to improve understanding of these posts and their potential for aiding GP recruitment, we undertook a qualitative study to explore trainees' perceptions of the experience of undertaking an educational ITP. The study takes an interpretive phenomenological approach using focus groups and one-to-one interviews which were audio-recorded, transcribed and thematically analysed. Emerging themes from the data captured participants' views of their experience of undertaking the posts, as well as the factors influencing their decisions to undertake the posts. The overarching theme found centred on identity formation. The study draws upon social learning theories to help understand and explain the themes identified and the influence on the individuals. For the interested stakeholder, this provides an insight into the individuals' experience and highlights important areas that could be targeted and utilised in the development of future general practice training models.

Trait and state interoceptive abnormalities are associated with dissociation and seizure frequency in patients with functional seizures.

OBJECTIVE: Dissociative traits represent a disturbance in selfhood that may predispose to, and trigger, functional seizures (FSs). The predictive representation and control of the internal physiological state of the body (interoception) are proposed to underpin the integrity of the sense of self ("minimal selfhood"). Therefore, discrepancies between objective and subjective aspects of interoception may relate to symptom expression in patients with FSs. Here, we tested whether individual differences in trait measures of interoception relate to dissociative symptoms, and whether state interoceptive deficits predict FS occurrence. METHODS: Forty-one participants with FSs and 30 controls completed questionnaire ratings of dissociation, and measures of (1) interoceptive accuracy (IA)-objective performance on heartbeat detection tasks; (2) trait interoceptive sensibility-subjective sensitivity to internal sensations (using the Porges Body Perception Questionnaire); and (3) state interoceptive sensibility-subjective trial-by-trial measures of confidence in heartbeat detection. Interoceptive trait prediction error (ITPE) was calculated from the discrepancy between IA and trait sensibility, and interoceptive state prediction error (ISPE) from the discrepancy between IA and state sensibility. RESULTS: Patients with FSs had significantly lower IA and greater trait interoceptive sensibility than healthy controls. ITPE was the strongest predictor of dissociation after controlling for trait anxiety and depression in a regression model. ISPE correlated significantly with FS frequency after controlling for state anxiety. SIGNIFICANCE: Patients with FSs have disturbances in interoceptive processing that predict both dissociative traits reflecting the disrupted integrity of self-representation, and the expression of FSs. These findings provide insight into the pathophysiology of functional neurological disorder, and could lead to novel diagnostic and therapeutic approaches.

An investigation into the preferred terminology for functional seizures.

There is considerable debate in the literature regarding what to call functional seizures, with terms such as pseudoseizures, nonepileptic attack disorder (NEAD), and dissociative seizures being used. Provision of an accurate diagnosis and coherent explanation is a vital first step in the management of functional seizures and can result in cessation or reduced frequency for some individuals. This study investigated preferences for and offensiveness of terms used to describe functional seizures, and expectations for recovery with psychological treatment. A sample of 87 healthy adults completed an online survey, in which eight different diagnostic terms were ranked in order of preference (1 - most preferred, 8 - least preferred): functional nonepileptic attacks (FNEA), dissociative seizures, functional seizures, psychogenic seizures, NEAD, pseudoseizures, conversion disorder, and hysteria. Replicating Stone and colleagues protocol, each term was investigated for five connotations. Offense scores were calculated from the number of participants who selected 'yes' to at least one of the negative connotations ('Putting it on', 'Mad', and 'Imagining Symptoms'). Expectations about the possibility of recovering through medical or psychological treatment were also recorded. Functional nonepileptic attack was ranked the highest preferred term with dissociative seizures and functional seizures closely following. Nonepileptic attack disorder was the least offensive term, with FNEA and functional seizures joint second. Unsurprisingly, the three least preferred terms were also the most offensive: pseudoseizures, conversion disorder, and hysteria. Expectations of nonrecovery from psychological treatment were lowest for terms implicating a psychological cause: pseudoseizures, dissociative seizures, psychogenic seizures, and hysteria. The results suggest that either the terms FNEA or functional seizures should be adopted by healthcare professionals and patients, as they are the most preferred, least offensive, and expectations for nonrecovery with psychological treatment were moderate compared with the other terms. Limitations and areas for future research are discussed.

Meat Bars: A Survey To Assess Consumer Familiarity and Preparation Parameters and a Challenge Study To Quantify Viability of Shiga Toxin-Producing Escherichia coli Cells during Processing and Storage.

Meat bars are dried snacks containing a mixture of meat, berries, and nuts. To explore consumer awareness of meat bars, we conducted two online, nationally representative surveys and established that 70.8% (743 of 1,050) of U.S. citizens were unfamiliar with this product. When asked to check all answers that applied, most of the 545 respondents (who were recruited based on their familiarity with meat bars) preferred beef (n = 385) as the protein source, followed by chicken (n = 293), pork (n = 183), and turkey (n = 179). Most meat bars were purchased from grocery stores (n = 447), followed by online orders (n = 130) and outdoor stores (n = 120). When asked specifically whether they made their own meat bars, 17.8% of respondents (97 of 545) replied "yes," the majority (52 of 97, 54%) of which obtained recipes online. Some 69.1% (67 of 97) measured the internal temperature of the meat during dehydration, but only 10.3% (10 of 97) confirmed the internal temperature by using a thermometer. Given the paucity of information available on the fate of pathogenic or spoilage bacteria associated with meat bars, as another component of this study, batter was prepared with or without encapsulated citric acid (ECA; 0.74%) added to a formulation of ground beef (65%; 90% lean, 10% fat), chopped pecans (15%), golden flaxseed flour (9.7%), chopped cranberries (5.0%), chopped sunflower seeds (3.1%), sea salt (1.1%), black pepper (0.8%), and celery powder (0.35%). Batter was inoculated (ca. 6.5 log CFU/g) with Shiga toxin-producing Escherichia coli (STEC), portioned by hand (40 ± 0.1 g each), and then dried in a commercial dehydrator. Regardless of the drying treatment, inclusion of ECA in the batter resulted in a pH decrease from ca. 5.5 to ca. 4.7 to 5.0 in the finished product. Without ECA, when meat bars were dried at 62.8°C for 6 h, 71.1°C for 4 h, or 62.8°C for 2 h and then 71.1°C for 2 h, levels of STEC decreased by ca. 6.2, 6.3, or 5.2 log CFU/g, respectively. With ECA, STEC decreased by ca. 6.0, 6.6, or 6.0 log CFU/g in meat bars dried at 62.8°C for 6 h, 71.1°C for 4 h, or 62.8°C for 2 h and then 71.1°C for 2 h, respectively. Our results confirmed that a ≥5.0-log reduction in STEC could be achieved in meat bars formulated with or without ECA under all dehydration conditions tested.

Functional seizures: An evaluation of the attitudes of general practitioners local to a tertiary neuroscience service in London.

OBJECTIVE: Functional seizures are a common functional neurologic disorder. Given their chronic nature, and the biopsychosocial factors involved in their etiology, general practitioners (GPs) play a crucial role in the care of these patients. However, little is known about the attitudes of GPs toward, and knowledge of, functional seizures. METHODS: The Atkinson Morley Regional Neuroscience Centre in London provides a comprehensive service to patients with functional seizures. As part of a service evaluation we conducted an online survey among local GPs over a 1-month period assessing their attitudes toward, and knowledge of, functional seizures. RESULTS: One hundred twenty of 974 surveyed GPs replied to the survey (12.3%). Approximately 75% of GPs readily use the term "pseudoseizures," and over 50% were not sure or did not think that functional seizures were involuntary. Nearly 30% believed, or were unsure as to whether, functional seizures occur only when patients are stressed. Despite approximately 50% of GPs expressing interest in getting involved in the management of these patients, a similar proportion do not feel confident in dealing with queries from patients with functional seizures. Although most GPs felt that neurology and psychiatry should be the primary caregivers in the diagnosis and management, respectively, of functional seizures, 50% were also of the opinion that neurology should be involved in the management of these patients. SIGNIFICANCE: This survey highlights the attitudes of, and descriptive terms used by, GPs toward patients with functional seizures. Our findings suggest a need for better and clearer provision of information to GPs about this condition.

Treating functional non-epileptic attacks - Should we consider acceptance and commitment therapy?

Patients who experience functional non-epileptic attacks (FNEA) are frequently seen in Neurology clinics. Diagnosis alone can result in cessation of attacks for some patients, but many patients require further treatment. There is evidence that certain psychological therapies, like cognitive-behavioral therapy (CBT) and psychodynamic interpersonal therapy (PIT) can be beneficial. Acceptance and commitment therapy (ACT) is a type of CBT that has been found to be effective at treating other somatic disorders, like epilepsy and chronic pain. In this paper, we explain what ACT is, the current evidence-base for its use, and the rationale for why it may be a beneficial treatment for patients who experience FNEA. We conclude that ACT is a potential treatment option for FNEA, and further research is required.

Evaluation of a pilot innovative cognitive-behavioral therapy-based psychoeducation group treatment for functional non-epileptic attacks.

A high proportion of patients presenting at epilepsy clinics experience functional non-epileptic attacks (FNEA), and while psychological treatment is generally thought to be the required intervention, evidence regarding psychological treatment of FNEA is limited. A small number of psychoeducation treatments have been evaluated, with promising results. As part of routine care within a neuropsychiatry service, a 3-session cognitive-behavior therapy- (CBT-) informed psychoeducation group was developed. Patients with comorbid epilepsy were included. The group's effectiveness was evaluated in terms of attack frequency, mood, illness perception, dissociative experiences, and patient feedback. Pre- and post-treatment data were obtained for 19 patients. The proportion of patients experiencing attacks significantly decreased, with almost 40% of treatment completers reporting being attack-free at the end of treatment. Significant improvements were also found on level of psychological distress, illness beliefs, and understanding of the condition. No significant changes in mood or general functioning were observed. High satisfaction was reported by almost all patients. Treatment outcome was not significantly affected by the level of dissociative experiences. The results suggest that CBT-based psychoeducation group treatment can be a beneficial part of treatment for those with FNEA, even for those experiencing high levels of dissociation. Further controlled studies with larger sample sizes are required.

Using silver to reduce catheter-associated urinary tract infections.

Many thousands of urinary tract infections (UTIs) are linked to the insertion of an indwelling urethral catheter (Saint et al 2000). Catheterisation is often prolonged unnecessarily (Saint et al 2002), thereby increasing the infection risk. In this audit of 133 medical and surgical patients who were catheterised in an acute NHS hospital trust, the potential of a new silver alloy hydrogel-coated catheter to reduce the rate of infection was demonstrated. Benefits were indicated in terms of reducing clinical risk to the patient and the financial costs associated with treating catheter-associated UTIs, representing a substantial cost saving for the NHS.

Catheter-associated UTIs in patients after major gynaecological surgery.

A group of nurses undertook an audit across two hospitals comparing the incidence of catheter-related urinary tract infections in patients who had catheters inserted during major gynaecological surgery. The data suggests that using an anaesthetic lubricating gel for catheterisation reduces urinary tract infection rates for these patients.