Benedetta Demartini

The role of alexithymia in the development of functional motor symptoms (conversion disorder)

Background The mechanisms leading to the development of functional motor symptoms (FMS) are of pathophysiological and clinical relevance, yet are poorly understood. Aim The aim of the present study was to evaluate whether impaired emotional processing at the cognitive level (alexithymia) is present in patients affected by FMS. We conducted a cross-sectional study in a population of patients with FMS and in two control groups (patients with organic movement disorders (OMD) and healthy volunteers). Methods 55 patients with FMS, 33 patients affected by OMD and 34 healthy volunteers were recruited. The assessment included the 20-item Toronto Alexithymia Scale (TAS-20), the Montgomery-Asberg Depression Rating Scale, the Reading the Mind in the Eyes’ Test and the Structured Clinical Interview for Personality Disorders. Results Alexithymia was present in 34.5% of patients with FMS, 9.1% with OMD and 5.9% of the healthy volunteers, which was significantly higher in the FMS group (χ2 (2)=14.129, p<0.001), even after controlling for the severity of symptoms of depression. Group differences in mean scores were observed on both the difficulty identifying feelings and difficulty describing feelings dimensions of the TAS-20, whereas the externally orientated thinking subscale score was similar across the three groups. Regarding personality disorder, χ2 analysis showed a significantly higher prominence of obsessive-compulsive personality disorder (OCPD) in the FMS group (χ2 (2)=16.217, p<0.001) and 71.4% of those with OCPD also reached threshold criteria for alexithymia. Conclusions Because alexithymia is a mental state denoting the inability to identify emotions at a cognitive level, one hypothesis is that some patients misattribute autonomic symptoms of anxiety, for example, tremor, paraesthesiae, paralysis, to that of a physical illness. Further work is required to understand the contribution of OCPD to the development of FMS.

Depressive symptoms and major depressive disorder in patients affected by subclinical hypothyroidism: a cross-sectional study.

Abstract The relationship between subclinical hypothyroidism and depression is still controversial. Our objective was to compare the prevalence of depressive symptoms and major depressive disorder in a population of patients affected by subclinical hypothyroidism and a control group without thyroid disease. The authors enrolled 123 consecutive outpatients affected by subclinical hypothyroidism undergoing follow-up at the endocrinology department of San Paolo Hospital in Milan and 123 controls without thyroid disease under the charge of general physicians. All patients and controls underwent an evaluation by means of a psychiatric interview; Hamilton Rating Scale for Depression (HAM-D); Montgomery-Asberg Depression Rating Scale (MADRS); and serum thyroid stimulating hormone, free T4, and free T3 levels. Patients were also screened for thyroid peroxidase antibodies and thyroglobulin antibodies. Patients affected by subclinical hypothyroidism had a prevalence of depressive symptoms of 63.4% at HAM-D and 64.2% at MADRS; 22 patients (17.9%) had a diagnosis of depressive episode (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria). The control group had a prevalence of depressive symptoms of 27.6% at HAM-D and 29.3% at MADRS, and only seven controls had a diagnosis of depressive episode. The prevalence of depressive symptoms between these two groups was statistically different. This study underlines a strong association between subclinical hypothyroidism and depressive symptoms, which could have some important diagnostic and therapeutic implications in the clinical practice.

A POSITIVE DIAGNOSIS OF FUNCTIONAL (PSYCHOGENIC) TICS

Functional tics, also called psychogenic tics or pseudo‐tics, are difficult to diagnose because of the lack of diagnostic criteria and their clinical similarities to organic tics. The aim of the present study was to report a case series of patients with documented functional tics and to describe their clinical characteristics, risk factors and psychiatric comorbidity. Also clinical tips are suggested which might help the differential diagnosis in clinical practice.

Long-term outcome of psychogenic nonepileptic seizures: The role of induction by suggestion☆

PURPOSE The aims of our retrospective observational study were to evaluate the long-term outcome of PNESs after communication of the diagnosis and to define predictors of good outcome. METHOD Twenty-seven consecutive patients with a certain diagnosis of psychogenic nonepileptic seizures (PNESs) were included in the study. Follow-up information was obtained from each participant through a questionnaire designed for the study. Regarding seizure frequency, the patients were asked to report how many seizures they had experienced on average every month before the communication of the diagnosis and after it. RESULTS After the communication of the diagnosis, the median seizure frequency had dropped to 4 every month (p < 0.001). Seventeen participants (63%) were seizure-free at follow-up, and a further five (18.5%) showed a greater than 50% improvement in seizure frequency. Regarding the predictive value of clinical and sociodemographic variables for PNES global outcome, the factors gender, education, economic status, interval of time from onset, comorbidity with epilepsy, psychiatric history, mental retardation, psychological therapy, psychiatric therapy, and the presence of stressful and traumatic events were not related to prognosis; the only factor associated with a better outcome was the diagnosis made after the induction of PNESs by suggestion (p = 0.000, χ(2) = 4.654). CONCLUSION A substantial majority of our patients became seizure-free with communication of the diagnosis as the only intervention. The use of the induction by suggestion test was an important predictor of good outcome.

Know thyself: Exploring interoceptive sensitivity in Parkinson's disease

BACKGROUND Although Parkinsons disease (PD) is defined by its motor symptoms, it is now well recognised that cognitive, affective and emotion domains are also impaired. The pathophysiology of these disabling non-motor symptoms (NMS) remains unclear; recently the involvement of limbic areas, including the insula, in the neurodegenerative process has been suggested to have a key role. These areas, and the insula in particular, are also been suggested as key regions for interoception; interoceptive sensitivity (IS) is a measure of the accuracy of perception of sensations from inside the body related to the function of internal organs. OBJECTIVES To evaluate IS in PD patients by means of a well-established task: the heartbeat perception task. Moreover, we evaluated possible correlations between IS and psychological, affective and disease-related characteristics as well as fatigue perception in PD patients. METHODS Twenty PD patients and 20 healthy subjects (HS) were included and underwent the heartbeat perception task. An extensive evaluation of motor, non-motor, affective and emotion domains was carried out. RESULTS PD patients showed lower IS than HS (0.58±0.2 vs 0.72±0.1; p=0.04). PD reported higher scores in scales assessing depression (Hamilton depression scale: 8.7±5.8 vs 6.2±7.5; p=0.04); anhedonia (Snaith-Hamilton Pleasure Scale: 26.8±9.7 vs 15.4±2.9; p=<0.001) and apathy (Apathy Evaluation Scale: 35.8±8.6 vs 27.8±6.8; p=0.008). No significant correlations were detected between IS and motor, non-motor, affective and emotion symptoms. CONCLUSIONS PD patients have reduced interoceptive sensitivity. Future studies are encouraged to evaluate the importance of interoception in understanding the pathophysiology of affective/emotional symptoms in PD.

Psychogenic non-epileptic seizures and functional motor symptoms : A common phenomenology?

OBJECTIVE Recent studies have attempted to compare patients affected by psychogenic non-epileptic seizures (PNES) to patients affected by functional motor symptoms (FMS) from a demographic, clinical and psychological perspective. Nevertheless, results are quite controversial and significant conclusions have not been drawn. The aim of our study was to evaluate the phenomenology of psychology of the two groups assessing levels of dissociation and its subcomponents, alexithymia and interoceptive sensitivity in patients with PNES and in patients with FMS. METHODS We conducted a cross-sectional study recruiting 20 patients with PNES, 20 patients with FMS and 20 healthy subjects as a control group. All subjects underwent: Dissociative Experience Scale (DES), Somatoform Dissociation Questionnaire (SDQ-20), Cambridge Depersonalization Scale (CDS), Toronto Alexithymia Scale (TAS-20), Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for anxiety (HAM-A), heart beat detection task. RESULTS Our data suggest that PNES group scored significantly higher than the healthy control group on a measure of detachment (CDS). Also at the DES, a measure of psychoform dissociation, PNES patients scored significantly higher than healthy subjects. On the other hand patients affected by FMS scored significantly higher than the healthy control group on the SDQ but they did not report more experiences of detachment on the CDS. Patients affected by PNES and FMS were significantly more alexithymic than healthy controls, with a third of them scoring >61 on the TAS-20. SIGNIFICANCE Our data show different psychological mechanisms underlying patients with PNES and patients with FMS. This might lead also to potential implications for treatment.

Sense of body ownership in patients affected by functional motor symptoms (conversion disorder).

BACKGROUND AND AIM Patients with functional neurological symptoms are commonly seen in neurological practice. Nevertheless their aetiopathology remains unclear. We have recently shown that patients affected by functional motor symptoms (FMS) present lower interoceptive awareness and higher alexithymia levels than healthy controls. Nevertheless sense of body ownership has never been studied in FMS patients. The aim of the present study was to systematically investigate the sense of body ownership, with the rubber hand illusion (RHI) paradigm, in patients with FMS and healthy controls. MATERIALS AND METHODS We included in the study 16 patients with FMS and 18 healthy controls (HC). Patients and HC were asked to complete the Toronto Alexithymia Scale (TAS-20) and the self-consciousness scale (self-objectification questionnaire). All participants underwent the RHI paradigm: illusionary experience was measured by self-report and by proprioceptive alteration. RESULTS A Mann-Whitney U test performed revealed that FMS (median=2.11) participants embodied the rubber hand to the same extent than HC participants (median=2.0, Z = -0.86, p>0.05, r = -0.15). The same test revealed no significant difference in the Proprioceptive Drift experience between FMS (median=0.0) and HC participants (median = -0.5, Z = -0.96, p>0.05, r = -0.16). CONCLUSIONS Our study revealed that sense of body ownership is not impaired in patients affected by FMS. This, together with the results from our previous experiment (studying the interoceptive awareness), supports the hypothesis that interoceptive awareness and sense of body ownership may be dissociated in patients with FMS.

Psychiatric issues in patients with headaches.

Comorbidities among headaches and psychiatric disorders have been consistently reported in several clinical studies and reviews. In this paper, we review some recent clinical studies on migraine and tension-type headaches associated with mood, anxiety and somatoform disorders, focusing on therapeutic strategies for the psychiatric disorders.

Impulsive compulsive behaviours in Parkinson's disease: patients' versus caregivers' perceptions.

Impulsive compulsive behaviours (ICB) are neuropsychiatric disorders that can complicate Parkinson’s disease (PD). ICB include pathological gambling, compulsive sexual behaviour, compulsive buying, and binge eating, together with punding and dopamine dysregulation syndrome [1]. The PD Impulsive-Compulsive Disorders Questionnaire (QUIP) is a validated instrument to assess the presence of ICB in PD [2, 3]. A recent study has showed that the QUIP scale is a sensitive instrument whether completed by the patients or by their informants and that when comparing the QUIP completed by the patients to the one completed by their informant, the patient/informant agreement in referring the presence of ICD was moderate [4]. Here we describe our experience and we aimed to evaluate the patients and their carers’ agreement in reporting the presence of ICB. Forty-six patients and their carers were evaluated before attending a conference on non-motor symptoms in PD held by experts in the matter. They all agreed to participate, provided informed consent and were included in the study. Patient’s demographical and clinical data were collected. Patients and their carers were asked to complete the QUIP separately and they were instructed to refer to patient’s behaviour in the past year, considering behavioural changes lasting for at least four consecutive weeks. We performed statistical analysis by means of SPSS version 21 (Statistical Package for Social Science). The degree of agreement between each patient and his/her carer was calculated using the Cohen’s K. Forty-six patients (37 % females; mean age 66.4 years, SD 7.4 years, range 47–78 years; disease duration 6.16 years, SD 2.97 years, range 2–14 years; mean Levodopa equivalent daily dose 698.8, SD 375.8) and 46 carers (63 % females; mean age 63.2 years, SD 8.3 years, range 45–76 years) were included in the study. The prevalence of compulsive gambling, sexual behaviour, buying, eating, hobbyism/punding, walkabout and medication overuse according to patients’ and their carers’ QUIPs are shown in Table 1. According to patients’ QUIP, 31 patients (67.3 %) reported the presence of at least one ICB. The same percentage was found analysing carers’ QUIP. The degree of agreement between each patient and his/ her carer was then calculated. We found 26 couples to have poor agreement (Cohen’s K\ 0.41) (Table 1). Within these 26 couples where the agreement was poor, we analysed the single sub-items of the QUIP to define for each couple: (a) for which item there was a poor agreement; and (b) in which direction was the disagreement (patient saying ‘yes’, caregiver ‘no’ or vice versa) (Table 1). In the 26 couples where the agreement was poor, patients tend to report more often than carers the presence of compulsive sexual behaviour, hobbyism/punding, walkabout and medication overuse. Viceversa compulsive gambling, buying and eating were more reported by caregivers than patients. The lowest degree of agreement was found for compulsive eating and hobbism/punding. & B. Demartini bennidemartini@hotmail.it

Dopamine agonist withdrawal syndrome (DAWS) in a patient with a microprolactinoma

Dopamine agonist withdrawal syndrome (DAWS) is a recently described syndrome where patients withdrawn from long-term treatment with dopamine agonists experience a constellation of neuropsychiatric and autonomic symptoms. It was first described by Rabinak and Niremberge1 in a cohort of patients with Parkinsons disease (PD), where most were withdrawing DA because of the development of impulse control disorders (ICD). Others have since published larger case series of PD patients2 ,3 confirming the common symptoms (depression, anxiety, fatigued, dysphoria, irritability, agitation, pain, sleep disturbances, diaphoresis and orthostatic hypotension) and that the overwhelming majority of patients who develop DAWS on withdrawal of DA experienced ICD while on DA. In retrospect, the non-motor syndrome reported to occur on sudden cessation of DA following deep brain stimulation surgery for PD4 could be a description of DAWS. The pathophysiology of this syndrome is still unclear but a sudden change in dopaminergic stimulation might be the causative mechanism5 as it is hypothesised for other acute emergency syndromes such as acute dystonic reactions and neuroleptic malignant syndrome, where similar psychiatric and autonomic …