Case report: Improvement in refractory functional seizures, depression, and quality of life with ketamine-assisted therapy.

Functional seizures, a primary subtype of functional neurological disorder (FND), are a known cause of serious neurological disability with an increasing awareness of their impact amongst the neuroscience community. Situated at the intersection of neurology and psychiatry, FND is characterized by a range of alterations in motor, sensory or cognitive performance, such as abnormal movements, limb weakness, and dissociative, seizure-like episodes. Functional seizures are known, in part, to have psychological underpinnings; however, the lack of effective and consistent treatment options requires research and novel approaches to better understand the etiology, diagnosis and what constitutes a successful intervention. Ketamine, a selective blocker of the N-methyl-D-aspartate receptor, has a well-established safety and efficacy profile. In recent years, ketamine-assisted therapy has shown increasing potential for treating a broad range of psychiatric conditions, building on its demonstrated rapid-acting antidepressant effects. Here we present a 51-year-old female with refractory daily functional seizures leading to significant disability and a medical history significant for major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). After unsuccessful treatment attempts, the patient underwent a novel protocol with ketamine-assisted therapy. After 3 weeks of ketamine-assisted therapy followed by 20 weeks of intermittent ketamine treatment and ongoing integrative psychotherapy, the patient's seizures were significantly reduced in frequency and severity. She experienced significant improvements in depressive symptoms and functional ability scores. To our knowledge, this is the first reported case describing improvement in functional seizures following ketamine-assisted therapy. While rigorous studies are needed, this case report encourages further investigation of ketamine-assisted therapy for functional seizures and other functional neurological symptoms.

Using interpersonal process recall to compare patients' accounts of resistance in two psychotherapies for generalized anxiety disorder.

In a trial examining whether cognitive-behavioral therapy (CBT) could be improved by integrating motivational interviewing (MI) to target resistance, MI-CBT outperformed CBT over 12-month follow-up (Westra, Constantino, & Antony, 2016). Given that effectively addressing resistance is both a theoretically and an empirically supported mechanism of MI's additive effect, we explored qualitatively patients' experience of resistance, possibly as a function of treatment. For 5 patients from each treatment who exhibited early in-session change ambivalence, and thus were at risk for later resistance, we conducted interpersonal process recall interviews after a session. Transcripts were analyzed with grounded theory and consensual qualitative research. A salient contrast in patient narratives was a sense of compliance engendered in standard CBT versus connection in MI-CBT. Yet both narratives supported the superordinate category of resistance as an interpersonal process triggered by patient perceptions of therapist beliefs and behaviors. Findings contribute to the conceptualization of resistance from patients' first-hand accounts.

Therapist emotional reactions and client resistance in cognitive behavioral therapy.

Although extensively discussed in theoretical papers, empirical studies of therapist emotional reactions to clients are lacking, particularly within the context of client resistance and cognitive-behavioral therapy (CBT). The present study examined the early positive and negative emotional reactions to clients of four therapists, together with observed client in-session resistance, and changes in resistance from early to midtreatment, in a sample of 30 outpatients receiving eight sessions (14 hr) of CBT for generalized anxiety disorder. Findings indicated that greater therapist early positive reactions to clients, especially liking, enjoyment, and attachment, were associated with significantly lower levels of client resistance midtreatment and greater reductions in client resistance from early to midtreatment. These effects were independent of therapist competence in delivering CBT, suggesting a potentially unique and important role for therapist feelings about clients beyond the skillful delivery of treatment techniques. Greater early negative therapist reactions to clients were less consistently related to client resistance but power struggles, and feeling drained, helpless, guilty, and frustrated were associated with higher levels of client subsequent resistance.

Client experiences of motivational interviewing for generalized anxiety disorder: a qualitative analysis.

While Motivational Interviewing (MI) has demonstrated efficacy, little is known about the mechanisms through which MI achieves beneficial effects or how clients perceive the process of MI. The present study addressed this gap through a qualitative analysis of client accounts following four sessions of MI for generalized anxiety disorder. Clients identified increased motivation for treatment and change, experiencing the therapist as empathic and MI as a safe place to explore their feelings regarding change. MI was also described as deviant from client initial expectations. Overall, the emergent understanding of MI derived from clients' post-treatment narratives was consistent with MI principles and processes.

A review of the outcomes of the recommendations made during paediatric telepsychiatry consultations.

Little is known about whether the recommendations made during telepsychiatry are actually implemented. We reviewed 100 telepsychiatry consultations, chosen randomly from a paediatric telepsychiatry programme serving rural communities in Ontario. Treatment recommendations had been made for each case reviewed and up to nine recommendations had been made for a single case. Twenty-seven percent of recommendations revolved around monitoring (10%), changing (9%), starting (4%), continuing (3%) and stopping (1%) medication. Case managers associated with 54 of the cases were interviewed to determine whether the recommendations had been implemented and to examine the barriers and facilitators to implementation. The results indicated that cooperation of both child and parent, clear communication of recommendations, involvement of the school and local health providers, stability of the agencies and availability of services were key components in the successful implementation of recommendations. The matter of technology or technological difficulties acting as a barrier to telepsychiatric consultations was not mentioned by case managers, suggesting that it was not a problem.