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Background.

Functional neurological symptoms (FNS) are somatic symptoms, which superficially resemble those of organic disorders of the nervous system, but for which no physical explanation can be found. Reports suggest that functional symptoms account for 11% of neurological outpatients or 9% of neurological hospital admissions (Carson, Ringbauer, Stone, McKenzie, & Warlow, 2000; Lempert, Dieterich, Huppert &

Brandt, 1990). Patients with functional symptoms report that their physical functioning is just as impaired as that of patients with identified organic disease1. Functional symptoms are often persistent (Reuber, Mitchell, Howlett, Crimlisk, & Grunewald, 2005; Stone, Sharpe, Rothwell, & Warlow,

2003; Crimlisk et al., 1998) and costly to health services and the economy. This means that it is important to develop effective and acceptable treatments.

 The most appropriate treatment for patients with functional neurological symptoms remains controversial. Non-randomised or uncontrolled observational studies suggest that neurological symptoms can respond to different forms of psychological treatment (Reuber, Howlett, & Kemp, 2005) and most experts consider psychological therapy as the treatment of choice.

 A dedicated psychotherapy service for patients with FNS has been operating in the department of neurology of Sheffield Teaching Hospitals NHS Foundation Trust since January 2003. The therapeutic approach used is based on a model of psychodynamic interpersonal therapy developed by Hobson and specially adapted for use with patients with emotionally based physical symptoms. This treatment has previously been shown to be helpful in the treatment of functional bowel disorders (Creed et al., 2003) The model has been further adapted for use with patients suffering from functional neurological symptoms who may have experienced a high level of trauma (Howlett & Reuber M., 2008).

The therapy consists of a 2 hour initial semi-structured assessment interview followed by up to 19 fifty-minute therapy sessions. This patient group is very heterogeneous, so therapy is tailored to the individual patient. Key issues are identified in the first session and form the basis of the rest of the therapy.

One issue which seems to arise in almost every patient referred is a difficulty in processing emotions effectively. They may be inhibited from expressing or sharing emotions, particularly concerning very painful issues from the past, or may be unable to identify or describe their own feelings. Others find it difficult to control their feelings, or experience intrusive and unwanted emotions. These problems with emotional processing are a particular target of the therapy offered. Patients are encouraged to process areas of unresolved emotions, recognise, ‘stay with’, express and describe feelings that arise in the therapy session and link them with associated bodily sensations and the content of the session. They are also encouraged to find safe contexts to share and express emotions within their daily lives.

Research questions

The planned research will use the EPS to explore emotional processing in patients receiving psychotherapy for FNS, and would consider:

1)   Whether patients with FNS have deficits in emotional processing and what the prevalent patterns are.  This would contribute towards an understanding of the aetiology of FNS, and validate the focus on emotional processing in the therapy.

2)   Whether different forms of FNS are linked to different styles of emotional processing. This would contribute to an understanding of the aetiology of different types of symptoms and whether they might involve different psychological mechanisms.

3)   Whether patients’ emotional processing profiles were linked to their cognitive and emotional representations of their illness.

4)   Whether different styles of emotional processing predict whether patients engage with and benefit from this model of psychological treatment. This might help in developing referral criteria for this often scarce treatment resource.

5)   Whether therapy results in changes in emotional processing.

6)   Whether changes in emotional processing correlate with improvements in physical symptoms, psychological functioning, health related functioning and illness perceptions.

Methodology

All patients referred to the service with functional neurological symptoms (currently about 70 per annum) will be invited to take part in the study.

Emotional processing will be measured using the Emotional Processing Scale (EPS) (Baker R, Thomas S, Thomas PW, & Owens M, 2007), a validated 25-item self-administered questionnaire developed to identify and quantify effectiveness and different styles of emotional processing.

The 25 item EPS has 5 subscales for suppression, signs of unprocessed emotion, unregulated emotion, avoidance and impoverished emotional experience.

Physical symptoms will be assessed by the referring neurologist. Psychological functioning will be measured using the short form of the CORE (Clinical Outcomes in Routine Evaluation) Outcome Measure (Evans et al., 2000). Health related functioning will be measured using the SF-36 Health Survey (Short Functioning) (Ware, Kosinski, & Gandek, 2000), and illness perceptions using the Brief Illness Perception Questionnaire (Broadbent, Petrie, Main, & Weinman, 2006). The Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994; Bagby, Taylor, & Parker, 1994) will also be used to measure patients’ ability to identify and describe emotions.

The scales would be administered at the point of referral, at the start of therapy, immediately after completion of therapy and at 6 month follow-up.

Overall benefits arising from the research

This study will clarify the role that disruptions in emotional processing play in the development of different forms of FNS and patient perceptions of their illness, contribute to the development of referral criteria for psychotherapy, demonstrate whether the therapy and is effective in improving emotional processing and whether this contributes to improvement in symptoms and functioning.

Reference List

Bagby, RM., Parker, J., & Taylor, GJ. (1994). The Twenty-Item Toronto Alexithymia Scale – I. Item selection and cross-validation of the factor-structure. Journal of Psychosomatic Research, 38, 23-32.

Bagby, RM., Taylor, GJ., & Parker, J. (1994). The Twenty-Two Item Toronto Alexithymia Scale – II. Convergent, discriminant and concurrent validity. Journal of Psychosomatic Research, 38, 33-40.

Baker R, Thomas S, Thomas PW, & Owens M (2007). Development of an emotional processing scale. Journal of Psychosomatic Research, 62, 167-178.

Broadbent, E., Petrie, K. J., Main, J., & Weinman, J. (2006). The brief illness perception questionnaire. J.Psychosom.Res., 60, 631-637.

Carson, A. J., Ringbauer, B., Stone, J., McKenzie, L., & Warlow, C. (2000). Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatients. J.Neurol.Neurosurg.Psychiatry, 68, 207-210.

Creed, F., Fernandes, L., Guthrie, E., Palmer, S., Ratcliffe, J., Read, N. et al. (2003). The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology, 124, 303-317.

Crimlisk, H. L., Bhatia, K., Cope, H., David, A., Marsden, C. D., & Ron, M. A. (1998). Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ, 316, 582-586.

Evans, C., Mellor-Clark, J., Margison, M., Barkham, M., McGrath, G., Connell, J. et al. (2000). Clinical Outcomes in Routine Evaluation: The CORE-OM. Journal of Mental Health, 9, 247-255.

Howlett, S. & Reuber M. An Augmented Model of Brief Psychodynamic Interpersonal Therapy for Patients with Non-Epileptic Seizures. Psychotherapy Theory, Research, Practice, Training, (in press).

Lempert, T., Dieterich, M., Huppert, D., & Brandt, T. (1990). Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol.Scand., 82, 335-340.

Reuber, M., Howlett, S., & Kemp, S. (2005). Psychologic treatment for patients with psychogenic nonepileptic seizures. Expert Opinion in Neurotherapeutics, 5, 737-752.

Reuber, M., Mitchell, A. J., Howlett, S., Crimlisk, C. H., & Grünewald, R. (2005). Functional symptoms in neurology: questions and answers. Journal of Neurology, Neurosurgery & Psychiatry, 76, 307-314.

Stone, J., Sharpe, M., Rothwell, P. M., & Warlow, C. P. (2003). The 12-year prognosis of unilateral functional weakness and sensory disturbance. Journal of Neurology, Neurosurgery & Psychiatry, 74, 591-596.

Ware, J. E., Kosinski, M., & Gandek, B. (2000). SF36 (R) Health Survey: Manual & Interpretation Guide. Lincoln, RI: Qualimetric Incorporated.