Psychological Therapy for FND Flashcards
What do most systematic reviews of psychological interventions for functional symptoms focus on?
Somatoform disorder rather than FND
What is a key factor to consider when evaluating the evidence for psychological treatment in FND?
Only the people who accept the offer of psychological treatment are included
What is the basis for CBT in FND?
▪️Symptoms are caused by a self-perpetuating cycle
▪️Based on interaction of different factors in domains including somatic, cognition, behaviour, emotions, and environment
What does a CBT framework model include?
▪️Predisposing factors
▪️Precipitating factors
▪️Perpetuating factors
What is the main focus on the CBT approach to FND?
Addressing or changing cognitions and heaviours that they have in interaction with their symptoms
What tasks might be involved in CBT for FND?
▪️Collaboration
▪️Agenda setting
▪️Behavioural experiments
▪️Dealing with negative automatic thoughts
▪️Problem solving
▪️Reattribution
PLUS specific modifications for different FNDs
How might you use CBT to address functional motor symptoms?
▪️Identify somatic misinterpretations, negative thoughts, illness beliefs etc
▪️Establish alternative hypotheses for bodily sensations
▪️Homework and review avoidances etc
What 3rd wave treatments are currently in the process of developing FND specific modifications?
▪️Acceptance and Commitment Therapy
▪️Mindfulness
How does CBT appear to compare to antidepressants and other behavioural therapies for somatoform and pain disorders?
All effective but CBT has much larger effect
Also lead to fewer severe symptoms
How does CBT compare to enhanced standard care (TAU + education, psych assessment, and brief counselling)?
▪️Small but significant benefit on severity long term
▪️No difference on functional disability and QoL
How do psychodynamic approaches compare to CBT for FND?
Broadly comparable
Both generakky improve symptoms, MH, wellbeing and function
What psychosociak interventions appear to be best for conversion or dissociative disorders?
▪️Behaviour therapy (plus inpatient care)
▪️Hypnosis
▪️Motivational interviewing + psychotherapy
What is the evidence for psychological intervention for chronic pain?
▪️Behavioural therapy only helps mood
▪️CBT has modest effect on pain, disability, mood, and negative cognitions
▪️BUT most effects don’t last long
How can you modify CBT for functional dizziness?
Addition of relaxation techniques and vestibular rehabilitation/stimulation
What is the evidence for the use of CBT + vestibular rehab/relaxation for functional dizziness?
Some improvement in functional ability and psychological state (e.g. anxiety, depression)
Largest effect on dizziness related outcome but still moderate
What is the treatment of choice for dissociative seizures?
Psychotherapy
What is the main issue with psychotherapy for dissociative seizures?
▪️No evidence based pathway
▪️Lack of consistent treatment availability
How does CBT plus SMC (neuropsychiatry) compare to SMC alone for dissociative seizures?
Some improvement in both but combination treatment much more likely to be seizure free at end of treatment
What is the CBT model for dissociative seizures?
▪️Seizures are dissociative responses to arousal
▪️Often when confronted with intolerable or fearful circumstances
▪️Occur with high frequency of somatic symptoms of anxiety
▪️Maintained by cycle of behavioural, cognitive, affective, physiological, and social factors (e.g. fear and avoidance)
What are the main CBT approaches to dissociative seizures?
▪️Graded exposure to feared situations
▪️Treatment of mood disorder
▪️Problem-solving techniques
▪️Cognitive techniques for dysfunctional thinking and dealing with trauma
▪️Seizure control techniques
What was the primary outcome of the CODES trial and what did they find?
▪️Monthly DS frequency at 12 months
▪️Fewer seizures in CBT+SMC group but not significant
What secondary outcomes showed strong significant improvements in CBT+SMC group of the CODES trial?
▪️Longer number of consequitive days seizure free
▪️Low impact of DS on everyday functioning
▪️Self and doctor rated global clinical improvement
▪️Patient satisfaction with treatment
What other secondary outcomes showed moderately significant improvements in CBT+SMC group of the CODES trial?
▪️Seizures less bothersome
▪️Better general health
▪️Lower distress
▪️Fewer depressive symptoms
What did the CODES trial conclude about CBT for DS?
▪️No difference in seizure frequency
▪️BUT may contribute to improvements in psychosocial functioning and perceptions of health
▪️Good compliance and satisfaction
What are the main limitations of the CODES trial?
▪️SMC may he too passive - need TAU control?
▪️Excluded epileptic seizures
▪️Not blind!
▪️SMC group may have received more pharmacological treatment?
▪️Possibly need trauma-focused approach in high proportion who have trauma histories
What are the main strengths of the CODES trial?
▪️Large sample and large number of involved centres and therapists
▪️High follow up rates
▪️Outcome assessments blind
▪️Good compliance
▪️No differences in AEs, SAEs or other harms
What moderators have been found to interact with CBT to influence outcome for DS?
▪️General (increased physical QoL for women)
▪️Depression symptoms (reduced monthly seizure frequency for those with high number of symptoms)
▪️Current M.I.N.I diagnosis (reduced monthly seizure frequency for those with at least one M.I.N.I diagnosis)
What are the main predictors of DS outcome with CBT?
Largely things we have no control over such as current employment, higher level of education, and no financial disability benefits
What did stronger belief in diagnosis predict?
Better mental health related quality of life
What psychotherapy treatment shows best results for DS reduction and secondary outcomes like depression, QoL and GF?
CBT informed psychotherapy plus medication (sertraline)
What effects have studies of psychoeducation found for DS?
▪️No/slight reduction in DS frequency or severity
▪️Improvement in psychosocial functioning
▪️Trend to less hospital use
What are the main components of psychoeducation for DS?
- Understanding DS
- Before and during seizures (e.g. identify signs, self-management)
- Improving life (e.g. identifying avoidance behaviours)
- Therapy blueprint (e.g. how to improve functioning in most valued areas of life)
What is motivational interviewing?
Technique to deal with issues of ambivalence about behavioural change
Effective for improving engagement and adherence in many conditions
What are the four processes of motivational interviewing?
- ENGAGING (forming open, patient-centred relationship)
- FOCUSING (help identity DS treatment as target for change)
- EVOKING (reflective listening to elicit reasons for wanting to treat DS)
- PLANNING (concrete plans for behavioural change)
How has MI been found to benefit DS?
▪️Increased adherence
▪️Decreased DS frequency
▪️Increased QoL
How has mindfulness therapy been shown to effect psychogenic non-epileptic seizures?
Improvements in:
▪️Seizure frequency
▪️Seizure intensity
▪️QoL
How might CBT-based self-help approaches benefit FND?
▪️Greater improvements in symptom profile
▪️Less belief in permanence of symptoms
▪️Greater satisfaction with care
How might the addition of physical activity to CBT help FMD?
▪️Possibly increases compliance
▪️Improvement in primary and secondary outcomes but not different from CBT alone
What is the focus of psychodynamic psychotherapy?
▪️Historical and early life experience
▪️Parenting dynamics
▪️Enduring personality traits
▪️Links between these and current life experiences and problematic emotions/behaviours
What is the goal of psychodynamic psychotherapy?
To reshape intrapsychic structure of patient to produce favourable symptom change based on theories of early childhood nurturing experiences and parenting dynamics
What is the evidence for psychodynamic psychotherapy in FMD?
▪️Mixed results
▪️Some show improvements on movement scores, depression, anxiety, and global function
▪️Others show no effect
What is the evidence for outpatient MDT approaches to FND?
▪️Psychodynamic interpersonal therapy
▪️Reduction in physical symptoms, mental health, and depression scores at 12 months
What are the main overall limitations of the evidence for psychological interventions for FND?
▪️Limited quality
▪️Potential bias
▪️Diverse patient characteristics
▪️Different diagnostic criteria
▪️What are the best outcomes and control groups?
What might be the best option for chronic somatic conditions?
Combined treatments
