Cochrane Systematic Review and Meta-analysis of the Impact of Psychological Treatments for People with Epilepsy on Health-related Quality of Life

Objective: Given the significant impact epilepsy can have on the Health Related Quality of Life (HRQoL) of individuals with this condition and their families, there is great clinical interest in evidence-based psychological treatments aimed at enhancing well-being in people with epilepsy (PWE). An evaluation of the current evidence is needed to assess the effects of psychological treatments for PWE on HRQoL outcomes in order to inform future therapeutic recommendations and research designs.Methods: The operational definition of 'psychological treatments' included a broad range of interventions that use psychological or behavioral techniques designed to improve HRQoL, psychiatric comorbidities, and seizure frequency and severity for adults and children with epilepsy. A systematic literature search was conducted in line with Cochrane criteria for randomized controlled trials (RCTs) and quasi-RCTs investigating psychological treatments using HRQoL outcome measures as primary or secondary outcome measures. Standard methodological procedures required by the Cochrane Collaboration were used for data collection and analysis. Results: Twenty-four completed RCTs were included in this review (2,439 participants). Based on satisfactory methodological homogeneity, data from nine studies (468 participants) providing Quality of Life in Epilepsy-31 (QOLIE-31) outcomes were pooled for meta-analyses showing significant mean changes for QOLIE-31 Total Score and six subscales. The significant mean changes of QOLIE-31 Total Score [mean improvement of 5.68 points (95% CI 3.11 to 8.24, p < 0.0001)] and three subscales (Emotional Well-being, Energy/Fatigue, Overall QoL) exceeded the threshold of Minimally Important Change (MIC), indicating a clinically meaningful post-intervention improvement of QoL. Overall, the meta-analysis quality of evidence was characterized as “moderate” due to risk of bias present in eight of the nine included studies 1, 2. A narrative synthesis was conducted for all trials and outcomes that were not entered in the meta-analysis.Significance: These results provide moderate quality evidence that psychological treatments for adults with epilepsy may enhance HRQoL in people with epilepsy

A Review and Expert Opinion on the Neuropsychiatric Assessment of Motor Functional Neurological Disorders

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of the initial neuropsychiatric assessment of functional movement disorders (FND-movt) and functional limb weakness/paresis (FND-par) have yet to be established. This is an important gap from both diagnostic and treatment planning perspectives. In this article, the authors performed a narrative review to characterize clinically relevant variables across FND-movt and FND-par cohorts, including time course and symptom evolution, precipitating factors, medical and family histories, psychiatric comorbidities, psychosocial factors, physical examination signs, and adjunctive diagnostic tests. Thereafter, the authors propose a preliminary set of clinical content that should be assessed during early-phase patient encounters, in addition to identifying physical signs informing diagnosis and potential use of adjunctive tests for challenging cases. Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported. Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation. Positive physical examination signs (e.g., Hoover's sign and tremor entrainment) are key findings, as one of the DSM-5 diagnostic criteria. The neuropsychiatric assessment proposed emphasizes diagnosing FND by using "rule-in" physical signs while also considering psychiatric and psychosocial factors to aid in the development of a patient-centered treatment plan

The role of evidence-based guidelines in the diagnosis and treatment of functional neurological disorder

Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike

Multicenter clinical assessment of improved wearable multimodal convulsive seizure detectors

Objective New devices are needed for monitoring seizures, especially those associated with sudden unexpected death in epilepsy (SUDEP). They must be unobtrusive and automated, and provide false alarm rates (FARs) bearable in everyday life. This study quantifies the performance of new multimodal wrist-worn convulsive seizure detectors. Methods Hand-annotated video-electroencephalographic seizure events were collected from 69 patients at six clinical sites. Three different wristbands were used to record electrodermal activity (EDA) and accelerometer (ACM) signals, obtaining 5,928 h of data, including 55 convulsive epileptic seizures (six focal tonic–clonic seizures and 49 focal to bilateral tonic–clonic seizures) from 22 patients. Recordings were analyzed offline to train and test two new machine learning classifiers and a published classifier based on EDA and ACM. Moreover, wristband data were analyzed to estimate seizure-motion duration and autonomic responses. Results The two novel classifiers consistently outperformed the previous detector. The most efficient (Classifier III) yielded sensitivity of 94.55%, and an FAR of 0.2 events/day. No nocturnal seizures were missed. Most patients had <1 false alarm every 4 days, with an FAR below their seizure frequency. When increasing the sensitivity to 100% (no missed seizures), the FAR is up to 13 times lower than with the previous detector. Furthermore, all detections occurred before the seizure ended, providing reasonable latency (median = 29.3 s, range = 14.8–151 s). Automatically estimated seizure durations were correlated with true durations, enabling reliable annotations. Finally, EDA measurements confirmed the presence of postictal autonomic dysfunction, exhibiting a significant rise in 73% of the convulsive seizures. Significance The proposed multimodal wrist-worn convulsive seizure detectors provide seizure counts that are more accurate than previous automated detectors and typical patient self-reports, while maintaining a tolerable FAR for ambulatory monitoring. Furthermore, the multimodal system provides an objective description of motor behavior and autonomic dysfunction, aimed at enriching seizure characterization, with potential utility for SUDEP warning

Outcome measurement in functional neurological disorder: a systematic review and recommendations.

OBJECTIVES We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes. METHODS A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group. RESULTS Five FND-specific measures were identified-three clinician-rated and two patient-rated-but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost-utility (eg, healthcare resource use and quality-adjusted life years). CONCLUSIONS There are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population

Non-Neuroanatomic Disorders in the 21st Century: Somatoform Disorders

A century ago, neurology and psychiatry were practiced in a unified framework as neuropsychiatry. In the early 20th century, divisions occurred in the fields and lines were drawn between those who evaluated and treated patients with epilepsy, strokes, and migraines, and those with anxiety, depression, and schizophrenia. These divisions resulted in a dichotomous view of the brain/mind and influenced how we assessed the two patient populations

Management of Somatoform Disorders: A Neuro-Psychiatric Perspective

Somatoform disorders (SD) present in adults and children with a combination of neurologic signs, underlying psychological conflicts and comorbid psychiatric disorders. The majority of SD do not have a laboratory test to confirm the diagnosis. The exception to the rule is in psychogenic nonepileptic seizures (PNES), where the gold standard of video electroencephalography and adjunctive tests are used in establishing the diagnosis of PNES

Non-Neuroanatomic Disorders in the 21st Century: Somatoform Disorders

A century ago, neurology and psychiatry were practiced in a unified framework as neuropsychiatry. In the early 20th century, divisions occurred in the fields and lines were drawn between those who evaluated and treated patients with epilepsy, strokes, and migraines, and those with anxiety, depression, and schizophrenia. These divisions resulted in a dichotomous view of the brain/mind and influenced how we assessed the two patient populations