P Shaw

Emotional memory and perception in temporal lobectomy patients with amygdala damage

Background: The human amygdala is implicated in the formation of emotional memories and the perception of emotional stimuli—particularly fear—across various modalities. Objectives: To discern the extent to which these functions are related. Methods: 28 patients who had anterior temporal lobectomy (13 left and 15 right) for intractable epilepsy were recruited. Structural magnetic resonance imaging showed that three of them had atrophy of their remaining amygdala. All participants were given tests of affect perception from facial and vocal expressions and of emotional memory, using a standard narrative test and a novel test of word recognition. The results were standardised against matched healthy controls. Results: Performance on all emotion tasks in patients with unilateral lobectomy ranged from unimpaired to moderately impaired. Perception of emotions in faces and voices was (with exceptions) significantly positively correlated, indicating multimodal emotional processing. However, there was no correlation between the subjects’ performance on tests of emotional memory and perception. Several subjects showed strong emotional memory enhancement but poor fear perception. Patients with bilateral amygdala damage had greater impairment, particularly on the narrative test of emotional memory, one showing superior fear recognition but absent memory enhancement. Conclusions: Bilateral amygdala damage is particularly disruptive of emotional memory processes in comparison with unilateral temporal lobectomy. On a cognitive level, the pattern of results implies that perception of emotional expressions and emotional memory are supported by separate processing systems or streams.

Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors

Objectives: To clarify risk factors for the development of schizophrenia-like psychotic disorders following temporal lobectomy, and to explore the possibility that the early postoperative period is a time of high risk for the onset of such chronic psychotic disorders. Methods: Patients who developed schizophrenia-like psychosis were identified from a series of 320 patients who had a temporal lobectomy for medically intractable epilepsy. The relationship of their disorders to both the operation and subsequent seizure activity was examined. Using a retrospective case–control design, risk factors for the development of schizophrenia-like psychosis were established. Results: Eleven patients who developed schizophrenia-like psychosis postoperatively were identified and compared with 33 control subjects who remained free of psychosis postoperatively. The onset of de novo psychotic symptoms was typically in the first year following the operation. No clear relationship between postoperative seizure activity and fluctuations in psychotic symptoms emerged. Compared with the controls, patients who become psychotic had more preoperative bilateral electroencephalogram (EEG) abnormalities, pathologies other than mesial temporal sclerosis in the excised lobe and a smaller amygdala on the unoperated side. Conclusions: Temporal lobectomy for medically intractable epilepsy may precipitate a schizophrenia-like psychosis. Patients with bilateral functional and structural abnormalities, particularly of the amygdala, may be at particular risk for the development of such psychoses.

A critical period for the impact of amygdala damage on the emotional enhancement of memory

The amygdala is crucial in modulating enhanced memory for emotionally arousing material. The authors provide evidence that unilateral lesions of the human amygdala arising early in development, but not in adulthood, are associated with a loss of the expected superior retrieval of emotionally arousing over neutral material. This adds to evidence for an early critical period in the development of amygdala function.

Progression, Symptoms and Psychosocial Concerns among Those Severely Affected by Multiple Sclerosis: A Mixed-Methods Cross-Sectional Study of Black Caribbean and White British People

Objective Multiple sclerosis is now more common among minority ethnic groups in the UK but little is known about their experiences, especially in advanced stages. We examine disease progression, symptoms and psychosocial concerns among Black Caribbean (BC) and White British (WB) people severely affected by MS. Design Mixed methods study of 43 BC and 43 WB people with MS (PwMS) with an Expanded Disability Status Scale (EDSS) ≥6 involving data from in clinical records, face-to-face structured interviews and a nested-qualitative component. Progression Index (PI) and Multiple Sclerosis Severity Score (MSSS) were calculated. To control for selection bias, propensity scores were derived for each patient and adjusted for in the comparative statistical analysis; qualitative data were analysed using the framework approach. Results Median EDSS for both groups was (6.5; range: 6.0–9.0). Progression Index (PI) and Multiple Sclerosis Severity Score (MSSS) based on neurological assessment of current EDSS scores identified BC PwMS were more likely to have aggressive disease (PI F = 4.04, p = 0.048, MSSS F = 10.30, p<0.001). Patients’ reports of the time required to reach levels of functional decline equivalent to different EDSS levels varied by group; EDSS 4: BC 2.7 years v/s WB 10.2 years (U = 258.50, p = 0.013), EDSS 6∶6.1 years BC v/s WB 12.7 years (U = 535.500, p = 0.011), EDSS 8: BC 8.7 years v/s WB 10.2 years. Both groups reported high symptom burden. BC PwMS were more cognitively impaired than WB PwMS (F = 9.65, p = 0.003). Thematic analysis of qualitative interviews provides correspondence with quantitative findings; more BC than WB PwMS referred to feelings of extreme frustration and unresolved loss/confusion associated with their rapidly advancing disease. The interviews also reveal the centrality, meanings and impact of common MS-related symptoms. Conclusions Delays in diagnosis should be avoided and more frequent reviews may be justified by healthcare services. Culturally acceptable interventions to better support people who perceive MS as an assault on identity should be developed to help them achieve normalisation and enhance self-identity.

A nurse-led mental health service for people with multiple sclerosis

BACKGROUND Mental health problems are under recognised and under treated in people with multiple sclerosis (MS). METHOD A nurse-led project linking MS and mental health services was evaluated. Data on all referrals and management from 2006 to 2008 were collected prospectively. RESULTS 127 referrals were received. 82% had depression, 53% had anxiety (45% both). 42% were offered case management; 52% received Cognitive Behaviour Therapy (CBT), 55% required initiation or alteration of psychiatric medications and 19% were referred to secondary care; 16% had made suicidal plans. Significant improvements in depression at 6months occurred, but not anxiety or fatigue. CLINICAL IMPLICATIONS This service provides a model of mental health provision for patients with long term neurological conditions, in particular MS.

Exploring meanings of illness causation among those severely affected by multiple sclerosis: a comparative qualitative study of Black Caribbean and White British people

BackgroundIllness attributions, particularly for those living with life limiting illnesses, are associated with emotional adjustment or psychological distress. Few studies have examined attributions among people severely affected by multiple sclerosis (PwMS), and specifically among from diverse communities. This study aimed to explore and compare the presence and construction of meanings among Black Caribbean and White British PwMS.MethodsCross sectional qualitative interviews were conducted among Black Caribbean (BC) and White British (WB) PwMS with an EDSS of ≥6.0 (severe disease). Data were analysed using the framework approach.Results15 BC and 15 WB PwMS were interviewed. Attributions were complex with most PwMS reporting multiple explanations. Uncertainty, represents the first theme surrounding the aetiology of MS where participants constantly rehearsed the “why me?” question in relation to their illness, a number expressing considerable frustration. The second theme, ‘logical and scientific’, was voiced more often by WB PwMS and accounts for a range of genetic/viral influences, stress, environmental and lifestyle factors. Third, the ‘supernatural’ illness attribution theme departs from a biomedical perspective and was reported often among BC PwMS. This theme included the sub-categories of tests of faith and divine punishment, a view although exclusive to BC participants but was sometimes in conflict with notions of modernity.ConclusionOur findings identify evidence of cross-cultural and intra-group diversity in relation to MS causation. A greater professional awareness of the processes used by PwMS from diverse communities to make sense of their situation will enable health care professionals to facilitate effective support for those in their care and channel relevant psychosocial resources to them. This requires heightened skills in communication and cultural competency.

REAL WORLD EXPERIENCE OF FINGOLIMOD IN MULTIPLE SCLEROSIS: THE LONDON AUDIT

Background Fingolimod is a licensed and NICE-approved disease modifying therapy (DMT) for people with relapsing multiple sclerosis (pwRMS). Objective To analyse the ‘real world’ experience of Fingolimod in two MS centres (Barts Health and Kings College). Methods Patients were identified through electronic medical records (March 2013–December 2015). Demographics, MS history and follow-up data were analysed. Results 215 pwRMS were prescribed Fingolimod as second-line DMT in 77.6% (n=167) and first-line in 21% (n=45). 71.6% switched from Interferon-beta or Glatiramer acetate. Thirteen JCV positive pwRMS switched from Natalizumab to Fingolimod, due to risk of PML. Fingolimod was discontinued in 15% (n=32) due to adverse effects (most frequently headache, in one case infection), pregnancy and ongoing disease activity (n=10). The absolute lymphocyte count was <0.2 in 7 cases. 16.3% (n=35) had at least one relapse during the observation period, 46% of which had ongoing MRI activity. Conclusions Our experience of Fingolimod as a treatment for pwRMS closely resembles the data from the original phase III clinical trials and supports the short-term safety and efficacy of Fingolimod in clinical practice. This collaboration between MS centres provides useful insights into the ‘real world’ experience of benefits and risks of DMTs for pwRMS.

COMPREHENDING THE INEXPLICABLE: QUALITATIVE ACCOUNTS OF BLACK CARIBBEAN AND WHITE BRITISH PEOPLE SEVERELY AFFECTED BY MULTIPLE SCLEROSIS

Background Multiple sclerosis is now more common among minority ethnic groups in the UK but little known little is known about how they attribute meanings to their illness and to what extent they are culturally shaped; meanings may influence adjustment outcomes and attitudes to service use. Aim To explore the cognitive organisation and meanings of MS among black Caribbean (BC) and white British (WB) people severely affected by their illness and to understand how these may be culturally constructed. Method Semi-structured qualitative interviews were conducted among Black Caribbean (BC) and White British (WB) people with MS (PwMS) with an EDSS of ≥6.0 (severe disease). Data were analysed using the framework approach. Results 15 BC and 15 WB PwMS were interviewed with mean ages of 46.6 and 56.9 years respectively. Attributions were complex, with most PwMS reporting multiple explanations. Uncertainty, represents the first theme surrounding the aetiology of MS where participants constantly rehearsed “why me?” question in relation to their illness, a number citing considerable frustration. The second main theme, ‘logical and scientific’, was voiced more often by WB PwMS and accounts for arrange of genetic/viral influences, stress, environmental and lifestyle factors. Third, the ‘supernatural’ illness attribution theme departs from a biomedical perspective and was reported more frequently among BC PwMS. This theme included the sub-categories of religious challenge and divine punishment, a view although exclusive to BC participants was sometimes in conflict with their notions of modernity. Conclusion We identify causal attributions play important roles in determining emotional responses to MS. Taken together these findings suggest not only considerable cultural diversity in relation to MS causation but also diversity within groups. This highlights the need for health professionals to investigate such beliefs, particularly if supernatural causes are considered inherently uncontrollable. This has important implications for help-seeking and symptom-reporting behaviours.