INVESTIGATING THE SUBJECTIVE EXPERIENCE OF LIVING WITH EPILEPSY OR PSYCHOGENIC NONEPILEPTIC SEIZURES

Psychogenic nonepileptic seizures (PNES) are paroxysmal events superficially resembling epileptic seizures. Although exploring the subjective experience is key in the management and care of patients with epilepsy or PNES, there is a lack of research into the subjective symptomologies. The primary aim of this thesis was to investigate the phenomenology and clinical implications (diagnostic, prognostic and therapeutic) of the lived experience of epilepsy or PNES. Firstly, a systematic synthesis of 21 qualitative studies investigating personal experiences of PNES was conducted. Five key themes emerged revealing experiences of treatment, impact to daily life, and emotional events, as well as differences between the seizure accounts of those with epilepsy. The first empirical study in this thesis explored a series of self-reported measures demonstrating that, subjective experiences could contribute to the diagnostic process as symptoms of panic associated with episodes of transient loss of consciousness could be used to distinguish between PNES and epilepsy or syncope. In study two, a series of multiple-regression analyses revealed that in both epilepsy and PNES, illness perception was a stronger predictor of health-related quality of life (HRQoL) when compared to demographic and condition-related factors. In study three, it was found that writing about experiences of living with a seizure disorder was associated with qualitative and quantitative benefits, including improved HRQoL one-month later. In the final series of studies, it was demonstrated that analysing and comparing individuals’ written accounts of PNES or epilepsy could help to improve our understanding towards some of the problems that individuals experience, as well as highlight clinical implications. In conclusion, research into the subjective experience of seizure disorders is a valuable area of research. More specifically, in-depth investigations are needed into the impact, prevalence and management of specific experiences, which include the voices of individuals that so far have been under-represented

A systematic review of psychological interventions in adults with pulmonary hypertension: Is the evidence-base disproportionate to the problem?

Introduction: Our understanding of the psychological impact of living with pulmonary hypertension (PH) is growing, particularly for how anxiety and depression present in this group. There is evidence for the use of psychological interventions in other chronic lung conditions; however, trials focusing on adults with PH have yet to be subject to a systematic review. Methods: We systematically searched four databases for evidence examining the effectiveness of psychological interventions for adults with PH. A narrative approach has been used to present findings. Results: Overall, 186 unique articles were identified of which four were suitable. Data was gathered from 143 individuals. Cognitive behavioural therapy (CBT), metacognitive therapy (MCT) or counselling were investigated. All three studies reported a significant reduction in anxiety and depression, and some secondary outcomes were also associated with change. Discussion: The evidence supporting the use of psychological therapies for adults with PH is promising, although limited. There is an urgent need for more research in this area to better understand how we can support this clinical group

Neurologists’ experiences of participating in the CODES study—A multicentre randomised controlled trial comparing cognitive behavioural therapy vs standardised medical care for dissociative seizures

Purpose We investigated neurologists’ experience of participating in the large CODES trial involving around 900 adults with dissociative seizures which subsequently evaluated the effectiveness of tailored cognitive behavioural therapy (CBT) plus standardised medical care versus standardised medical care alone in 368 patients with dissociative seizures. Method We asked all neurologists referring patients with dissociative seizures to the CODES study to complete a 43-item online survey. This examined neurologists’ (i) demographics, (ii) knowledge of dissociative seizures before and after their involvement in the CODES trial, (iii) clinical practice before, during and since their involvement, and (iv) their experience of the CODES trial. Results Forty-three (51%) neurologists completed the questionnaire. Only about half of neurologists could make referrals to psychological intervention specific for dissociative seizures before and after the trial. One-third of doctors reported having changed their referral practice following their involvement. The majority (>69%) agreed that patient satisfaction with different aspects of the trial was very high, and 83.7% thought that it was easy to recruit patients for the study. Over 90% agreed they would like the treatment pathway to continue. Respondents found different elements of the trial useful, in particular, the patient factsheet booklet (98%), diagnosis communication advice (93%) and the CBT package (93%). Conclusions Neurologists participating in CODES generally found it easy to recruit patients and perceived patient satisfaction as very high. However, 46.5% of neurologists could not offer psychotherapy once the trial had finished, suggesting that problems with lack of access to psychological treatment for dissociative seizures persist

FIRST-2MASS Red Quasars: Transitional Objects Emerging from the Dust

We present a sample of 120 dust-reddened quasars identified by matching radio sources detected at 1.4 GHz in the FIRST survey with the near-infrared 2MASS catalog and color-selecting red sources. Optical and/or near-infrared spectroscopy provide broad wavelength sampling of their spectral energy distributions that we use to determine their reddening, characterized by E(B-V). We demonstrate that the reddening in these quasars is best-described by SMC-like dust. This sample spans a wide range in redshift and reddening (0.1 < z < 3, 0.1 < E(B-V) < 1.5), which we use to investigate the possible correlation of luminosity with reddening. At every redshift, dust-reddened quasars are intrinsically the most luminous quasars. We interpret this result in the context of merger-driven quasar/galaxy co-evolution where these reddened quasars are revealing an emergent phase during which the heavily obscured quasar is shedding its cocoon of dust prior to becoming a "normal" blue quasar. When correcting for extinction, we find that, depending on how the parent population is defined, these red quasars make up < 15-20% of the luminous quasar population. We estimate, based on the fraction of objects in this phase, that its duration is 15-20% as long as the unobscured, blue quasar phase.Comment: 21 pages, 17 figures plus a spectral atlas. Accepted for publication in the Astrophysical Journa

Taking the Long View: What Does a Child Focus Add to Social Protection?

Recognising that many indicators of vulnerability among children, such as malnutrition or poor educational performance, might reflect intergenerational problems has profound implications for the design and implementation of social protection programmes. Treating the symptoms of these problems is of course essential: a malnourished child needs immediate nutritional support and a child who is failing at school needs special attention. But the argument of this paper is that ‘taking the long view’ is imperative if the reasons why children are malnourished, or failing, are to be correctly identified and adequately addressed. Importantly, the analysis implies directing interventions not exclusively at the children who are at risk, but at others in society who are responsible for the care of children

Coping with stress: a pilot study of a self-help stress management intervention for patients with epileptic or psychogenic non-epileptic seizures

Purpose: Many patients with epilepsy or psychogenic non-epileptic seizures (PNES) experience high levels of stress. Although psychological interventions have been developed for seizure disorders, few patients can currently access them. We aimed to assess the acceptability and feasibility of a self-help intervention targeting stress in patients with seizures, and to provide preliminary evidence for its effectiveness. Method: Patients were recruited from outpatient neurology clinics and randomised to an immediate intervention group (n=39), who received the intervention at baseline, or a delayed intervention group (n=43), who received the intervention one month post-baseline. Participants completed self-report questionnaires measuring stress (SSSI), anxiety (GAD-7), depression (NDDI-E), quality of life (EQ-5D), seizure severity and frequency (LSSS-3) at baseline, and at one- and two-month follow-up. Participants also provided telephone feedback. The intervention consisted of a self-help stress management workbook based on an integrative stress model framework. Results: Although the rate of participants failing to return follow-up information at two months was approximately 50%, those who completed the trial found the intervention acceptable; with the majority rating it as helpful (63.6%) and that they would recommend it to others with seizures (88.1%). A significant reduction in self-reported stress (p = 0.01) with a medium effect size (dz = 0.51) was observed one-month post-intervention. There were no significant changes in any other measures. Conclusion: The intervention was perceived to be acceptable, safe and helpful by participants. It could be a useful complementary treatment option for reducing stress experienced by patients living with seizure disorders. Further evaluation in a larger trial is warranted

Cognitive–behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT

BACKGROUND: Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures. DESIGN: This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. SETTING: This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services. PARTICIPANTS: Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. INTERVENTIONS: Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. MAIN OUTCOME MEASURES: The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. RESULTS: In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway. LIMITATIONS: Unlike outcome assessors, participants and clinicians were not blinded to the interventions. CONCLUSIONS: There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy. FUTURE WORK: Examination of moderators and mediators of outcome. TRIAL REGISTRATION: Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information

Superdisks in Radio Galaxies: Jet-Wind Interactions

Taking a clue from their sharp-edged (strip-like) morphology observed in several cases, a new mechanism is proposed for the formation of the emission gaps seen between the radio lobes of many powerful extragalactic double radio sources. Canonical understanding of the radio gaps invokes either blocking of the back-flowing lobe plasma by the denser interstellar medium (ISM) of the host galaxy, or "squeezing" of the radio bridge in the middle through buoyancy force exerted by either the ISM or the surrounding intra-cluster medium (ICM). These pictures encounter difficulties in explaining situations where the sharp-edged radio gaps associated with non-cluster radio galaxies have widths running into several tens (even hundreds) of kiloparsecs. More particularly, the required dense high-pressure ISM/ICM is likely to be lacking at least in the case of high-redshift radio galaxies. We propose here that radio emission gaps in at least such cases could arise from a dynamical interaction between the powerful thermal wind outflowing from the active galactic nucleus and the back-flowing synchrotron plasma in the two radio lobes, which occurs once the rapidly advancing jets have crossed out of the wind zone into the intergalactic medium. A simple analytical scheme is presented to explore the plausibility of the side-ways confinement of the thermal wind by the radio lobe pair, which would "freeze" pancake shaped conduits in the space, along which the hot, metal enriched wind from the AGN can escape (roughly orthogonal to the radio axis). Some other possible consequences of this scenario are pointed out.Comment: 10 pages, 3 figures [one .jpg], official version published in MNRA

WASp-deficient B cells play a critical, cell-intrinsic role in triggering autoimmunity

In a manner dependent on CD4 T cell help and Toll-like receptor signals, B cells lacking WASp induce autoantibody production and autoimmune disease in mice