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. 2019 Nov 5;93(19):e1787-e1798.
doi: 10.1212/WNL.0000000000008442. Epub 2019 Oct 4.

Clinical and neural responses to cognitive behavioral therapy for functional tremor

Alberto J Espay  1 , Scott Ries  2 , Thomas Maloney  2 , Jennifer Vannest  2 , Erin Neefus  2 , Alok K Dwivedi  2 , Jane B Allendorfer  2 , Lawson R Wulsin  2 , W Curt LaFrance  2 , Anthony E Lang  2 , Jerzy P Szaflarski  2
Affiliations

Clinical and neural responses to cognitive behavioral therapy for functional tremor

Alberto J Espay et al. Neurology. .

Erratum in

Abstract

Objectives: To evaluate changes in tremor severity and motor/emotion-processing circuits in response to cognitive behavioral therapy (CBT) delivered as treatment for functional tremor (FT), the most common functional movement disorder in adults.

Methods: Fifteen patients with FT underwent fMRI with motor, basic-emotion, and intense-emotion tasks before and after 12 weeks of CBT. Baseline fMRI was compared to those of 25 healthy controls (HCs). The main clinical endpoint was the tremor score (sum of severity, duration, and incapacitation subscores) adapted from the Rating Scale for Psychogenic Movement Disorders (PMDRS) assessed by a blinded clinician. CBT responders were defined as those with PMDRS score reduction >75%. Anatomic and functional brain images were obtained with a 4T MRI system. Generalized linear model and region-of-interest analyses were used to evaluate before-versus-after treatment-related changes in brain activation.

Results: CBT markedly reduced tremor severity (p < 0.01) with remission/near remission achieved in 73.3% of the cohort. Compared to HCs, in those with FT, a functionally defined fMRI region of interest in the anterior cingulate/paracingulate cortex showed increased activation at baseline and decreased activation after CBT during basic-emotion processing (p = 0.012 for CBT responders). Among CBT responders, the change in anterior cingulate/paracingulate was more significant in those with more severe baseline depression (r = 0.75, p < 0.01).

Conclusions: Tremor severity improved significantly after CBT. The improvement was associated with changes in the anterior cingulate/paracingulate activity, which may represent a marker of emotional dysregulation in FT and a predictor of treatment response.

Classification of evidence: This study provides Class III evidence that CBT significantly improves tremor severity in patients with functional tremor.

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Figures

Figure 1
Figure 1. Clinical changes after CBT.
(A) Box-whisker plots visually summarize the distribution of responses before and after cognitive behavioral therapy (CBT). (B) Distribution of response categories based on change in Rating Scale for Psychogenic Movement Disorders (PMDRS) score after CBT.
Figure 2
Figure 2. Differences in fMRI activation for the basic-emotion task after small volume correction.
(A) Differences between participants with functional tremor (FT) and healthy controls (HCs). Regions in red showed greater activation in FT. (B) Region over which small volume correction was implemented. (C) Changes from before cognitive behavioral therapy (CBT) to after CBT in patients with FT. Regions in red showed greater activation before CBT that decreased after CBT. ROI = region of interest.
Figure 3
Figure 3. Differences in fMRI activation for the intense-emotion task after small volume correction.
(A) Differences between participants with functional tremor (FT) and healthy controls (HCs). Regions in blue showed greater activation in HCs. (B) Region over which small volume correction was implemented.
Figure 4
Figure 4. Changes in activation and depression scores.
A strong correlation was found between Hamilton Depression Scale (HAM-D) scores and changes in activation, before cognitive behavioral therapy to after CBT, in the anterior cingulate/paracingulate region (r2 = 0.56, p = 0.008) among those patients with FT who responded to CBT therapy.
See this image and copyright information in PMC

Comment in

References

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