Cognitive behavioural therapy for adults with dissociative seizures (CODES): a ... multicentre, randomised controlled trial (2020) Goldstein, Chalder

Then they use the fact they have these wonderful results for CBT as proof that they were right that there is no disease just psychological problems. CBT itself is not the problem. It is a bit trivial but it can be helpful if your life is in upheaval. It is the assumption that there is no disease - so why use money to research finding a cause or a treatment? and that if you are still ill after a 6 week course it is your own fault so we have no sympathy for you and no benefit money.

 

Whatever happened to this? Did Perez respond to the Tuller letter? @dave30th

I sort of liked Perez’ admission that that he didn’t really care about what the data showed—very frank of him!

 

CBT for toenail fungus

 

No, but he's published other stuff since then.

 

Maybe that’s what I should try next, nothing else has shifted it!

 

This recent article in the BMJ from Stone, Burton and Carson, "Recognising and explaining functional neurological disorder" (thread here: https://www.s4me.info/threads/recog...neurological-disorder-2020-stone-et-al.17413/)

Cites CODES [19] to justify the claim that RCTs support the use of CBT across the range of FND:

 

And so it goes on......

 

It is one thing to classify FND as rooted in brain dysfunction caused by changes as a result of childhood adversity then say it can be treated by CBT. We know they are wrong but maybe they believe it.

But to then say that CBT is successful when they get a slight improvement in anxiety about the disease when the patients never went to a doctor about anxiety is not useful or cost effective at all.

Then how can they say it was successful when they believe that the physical symptoms are a way of expressing psychological distress. If those symptoms remain then the psychological distress must still be there even if CBT makes a small difference in the emotions they are capable of expressing.

So everything makes no sense even if their theory of FND is correct.

FND as a concept is like candy floss. It disappears with even a superficial examination.

 

https://www.scientificamerican.com/article/decoding-a-disorder-at-the-interface-of-mind-and-brain/

https://twitter.com/user/status/1339026848206835713

 

When the description of the situation contains the problem. When your "first-line intervention" is literally pseudoscientific horseshit, yeah, prognosis will remain poor. Doesn't take a genius to see the problem here.

 

@Sean, and all others who have noted this particular BPS policy. Very concerning: applying this theory to all health problems, irrespective of cause. It doesn't make sense. And, can hinder effective treatment.

In addition to ME, we all know of examples where health problems dismissed as psychological/imaginary actually required biomedical treatment. One such example: repeated complaints of fatigue dismissed; finally diagnosed as Leukemia less than a week before death.

 

I had not noticed this. It takes chutzpah to cite your null results as proof of success. It might be worth alerting the journal.

 

I can drive myself crazy by looking at the 'cited by' section on papers like this.

I can't access the full text for this new one citing CODES, but the abstract says "Multiple randomized trials support the efficacy of cognitive behavioral therapy in treating functional seizures, and other forms of psychotherapy, such as mindfulness-based psy-chotherapy and psychodynamic psychotherapy, may be effective"

https://www.sciencedirect.com/science/article/abs/pii/S073386272030095X

CODES is reference 19 here:

"In the last 15 years, there have been significant advances in the treatment of PNES, with the establishment of cognitive behavior therapy (CBT) with or without a selective serotonin-reuptake inhibitor (SSRI) antidepressant.16-19"

https://journals.sagepub.com/doi/full/10.1177/1535759720955166

[I'm getting a lot of fails with sci-hub - maybe this is an area where there's even less interest than usual?]

I hadn't realised how bad things were more broadly within academia when first getting outraged by the spin around PACE.

 

It would be interesting to check citations for CODES in a year and see if any are accurate or all are promoting it as showing how great CBT is for seizures

 

That was the open access one I didn't need sci-hub for. I was feeling pretty miffed when I thought you'd just been able to access one of the articles I'd struggled with.

-edit: Thanks @Sly Saint - just reread my post and it sounded more churlish than jokey in the way I'd intended.

 

I will boldly predict the response: "yes, you are correct, now what do you want us to do about it?" And if you reply that they should correct the article they will be puzzled as to why you would want such a bizarre thing.

Give or take. BMJ gonna BMJ.

 

As far as I understand it, this looks to have been published by an NIHR publication.

Cognitive behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT

This trial showed that there was no significant benefit of adjunctive dissociative-specific CBT in reducing the frequency of dissociative (non-epileptic) seizures at 12 months.

Abstract

Background
Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited.

Objectives
To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive–behavioural therapy for adults with dissociative seizures.

Design
This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial.

Setting
This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive–behavioural therapy services.

Participants
Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017.

Interventions
Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive–behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care.

Main outcome measures
The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness.

Results
In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive–behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1–35 dissociative seizures); cognitive–behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0–20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive–behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7–12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect –0.39, 95% confidence interval –0.61 to –0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive–behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval –0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive–behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway.

Limitations
Unlike outcome assessors, participants and clinicians were not blinded to the interventions.

Conclusions
There was no significant additional benefit of dissociative seizure-specific cognitive–behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive–behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive–behavioural therapy.

Open access, https://www.journalslibrary.nihr.ac.uk/hta/hta25430#/abstract

 

I seem to remember in the interview (https://www.s4me.info/threads/cogni...20-goldstein-chalder.15251/page-4#post-273720)

Chalder admits that there was no reduction in frequency of seizures, but then goes on to say that their QoL improved though......

 

Just had a look at the paper and the authors, clicked on the "on behalf of the CODES study group" and now have to cope with being confronted with that number of members (in addition to the 17 authors) ....



https://www.sciencedirect.com/science/article/pii/S2215036620301280#bfn2

Edited to add: link to David Tuller's take on the CODES study paper:

https://www.virology.ws/2020/06/27/trial-by-error-my-letter-to-author-of-codes-commentary/

 

yes, amazing--"We had null results from our primary outcome, which we have agreed was the primary outcome for more than a decade, and so have now decided that quality of life is more important to patients anyway and that reduction of seizures is not the appropriate primary outcome." It's complete bullshit. In fact, the non-intervention group had a greater reduction in the number of seizures than the group that received CBT specifically designed by Professor Chalder to reduce the number of seizures. I wrote a few blogs about that nonsense. It has since been cited as evidence that CBT is good for so-called PNES.