Treatment of Functional Movement Disorders With Psychotherapy

Objectives:

This is an exploratory study of two options for treating functional movement disorders (FMD):

• Group psychotherapy
• Cognitive behavioral therapy (CBT)-based guided self-help.

Study population:

We intend to study adult patients with diagnoses of FMD seen by the Human Motor Control Section Clinic (HMCS) and who live in the Washington-Baltimore metropolitan area for group psychotherapy as well as patients who live out of the area for CBT-based guided self-help.

Design:

Patients will be screened for participation through protocol 07-N-0190 ( Neurobiology of Psychogenic Movement Disorder and Non-Epileptic Seizures ). Those who meet the inclusion criteria and who live locally will be invited to participate in a treatment study of group psychotherapy. The duration of the study for each patient is one year. Local patients who meet the inclusion criteria will be divided into two groups of 10 patients each. Accrual will be gradual. All 10 patients in each group will start simultaneously. All participants will undergo an initial assessment, followed by an assessment at 3, 6, and 12 months. The primary endpoint will be assessed at 6 months. At the end of the study, all subjects will undergo the same MRI studies they completed as part of protocol 07-N-0190 baseline assessment. Patients will be evaluated with the scales described below.

Those who meet the inclusion criteria and who live locally will be invited to participate in a treatment study of group psychotherapy. Local patients who meet the inclusion criteria will be divided into two groups of 10 patients each. Accrual will be gradual. All 10 patients in each group will start simultaneously. All group participants will be asked to sign a therapy contract , a nonbinding group therapy conduct guideline.

Patients who are out-of-town and meet the inclusion/exclusion criteria will be invited to join the CBT-based guided self-help arm. They will be randomized in two groups of 20 patients each. One group will undergo CBT-based guided self-help; the other will be randomized to standard of care. Standard of care is defined as pharmacological or other treatment modalities excluding CBT or group psychotherapy (the studied modalities). Subjects will be included on a rolling basis, and therapy will be delivered approximately once every two weeks for a total of six sessions. Participants will be instructed in the use of CBT-based self-help workbooks aimed at treating functional neurological symptoms (Overcoming unexplained neurological symptoms: a five areas approach by Dr. Chris Williams, 2011, Hodder and Arnold). Total duration of the intervention will be about 6 months. Subjects will undergo the same assessments as patients in the group psychotherapy arm of the study at the same time points. Only participants in the standard of care arm who successfully complete the whole study will be offered the CBT-based guided self-help therapy after study completion.

Outcome measures:

Primary Outcome measure

-Ability to participate in social roles and activities (Neuro-QOL Item Bank) at 6 months after initiation of therapy.

Secondary Outcome Measures

• Clinical global impression of severity (CGI).
• Subjective and objective depressive and anxiety symptoms, measured with the Beck Depression Inventory (BDI), Hamilton Depression Rating Scale-17, State Trait Anxiety Inventory (STAI) and Hamilton Anxiety Scale.
• Patient and physician rated assessment of disease severity (5 point Likert scales).
• Somatic symptoms (SCL-90).
• Insight, measures with the Brown Assessment of Beliefs Scale (BABS)
• Similar measures at 12 months after initiation of therapy.
• MRI studies (resting state BOLD fMRI, DTI, VBM) comparison between baseline (protocol 07-N-0190) and 6 months after initiation of therapy.

• INCLUSION CRITERIA:
• Must have participated in Protocol 07-N-0190 ( Neurobiological studies of psychogenic movement disorder and non-epileptic seizure )
• Diagnosis of clinically definite FMD utilizing Fahn and Williams criteria. The diagnosis must be made by a neurologist
• Patients who have active movement symptoms at baseline and score at least 20 percent less than the maximum score on the Neuro-QOL Item Bank
• Able to give informed consent
• All participants should be English-speaking
• Age 18 or older
• Willingness to come without reimbursement to treatment visits for up to 6 months
• Willingness to remain on the same medications for the entire duration of the study

Exclusion criteria

• Have significant neurological disorders (primary or comorbid) such as neurodegenerative disorders, stroke, movement disorders or epilepsy
• Patients with psychotic disorders or bipolar disorder
• Patients with history of alcohol and substance use disorders within the last year, as defined by the DSM-IV-TR (nicotine and caffeine use is not criterion for exclusion)
• Current suicidal/homicidal ideation
• Disease severity requiring inpatient treatment. Chronic pain requiring treatment with narcotic medication

ADDITIONAL EXCLUSIONAL CRITERIA FOR MRI:

• Patients with movement symptoms at rest that may substantially inhibit resolution, comfort, or safety of MRI
• Previous history of or MRI findings consistent with brain tumors, strokes, trauma or arterial venous malformations
• History of traumatic brain injury with loss of consciousness or amnesia lasting greater than a few seconds
• Contraindication to MRI
• Pregnancy
• Patients with current post-traumatic stress disorder, panic disorder or obsessive compulsive disorders
• Patients on tricyclic antidepressants or antiepileptic medications.