Neuropsychological dysfunction, specifically impairment of set-shifting and error monitoring, contributes to poor insight in psychosis. Specific relations with different dimensions of insight and the putative role of metacognitive functions require further study.

Background Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. MethodsIn this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544.

There is little evidence to guide the management of depression that has not responded to a course of antidepressants. Treatment-refractory depression is an important public health problem and large pragmatic trials are needed to inform clinical practice.

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<b><i>Background:</i></b> Capgras’ delusion has captured psychiatrists’ imaginations, but the clinical features of the delusion have rarely been studied and presented systematically. <b><i>Aims:</i></b> The present study systematically reviews all case reports on Capgras’ delusion in the English language in order to better understand differences between organic and functional aetiologies. <b><i>Methods:</i></b> All medical and psychiatric databases were searched, as were the bibliographies of published case reports, narrative reviews, and book chapters. <b><i>Results:</i></b> A total of 258 cases were identified from 175 papers. Functional Capgras’ delusion was more associated with a wider variety of imposters; multiple imposters; other misidentification syndromes; auditory hallucinations; other delusions; and formal thought disorder. Organic cases were associated with age; inanimate objects; memory and visual-spatial impairments; right hemispheric dysfunction; and visual hallucinations. Executive dysfunction and aggression were associated with both types. <b><i>Conclusions:</i></b> Specific features of the ­Capgras’ delusional content and associated signs point to either organic or functional aetiology. The delusion is more amorphous than many theorists have supposed, which challenges their explanatory models.

Psychotic disorders represent a relatively rare but serious comorbidity in epilepsy. Current epidemiological studies are showing a point prevalence of 5.6% in unselected samples of people with epilepsy going up to 7% in patients with temporal lobe epilepsy, with a pooled odds ratio of 7.8 as compared with the general population. This is a narrative review of the most recent updates in the management of psychotic disorders in epilepsy, taking into account the clinical scenarios where psychotic symptoms occur in epilepsy, interactions with antiepileptic drugs (AEDs) and the risk of seizures with antipsychotics. Psychotic symptoms in epilepsy can arise in a number of different clinical scenarios from peri-ictal symptoms, to chronic interictal psychoses, comorbid schizophrenia and related disorders to the so-called forced normalization phenomenon. Data on the treatment of psychotic disorders in epilepsy are still limited and the management of these problems is still based on individual clinical experience. For this reason, guidelines of treatment outside epilepsy should be adopted taking into account epilepsy-related issues including interactions with AEDs and seizure risk. Second-generation antipsychotics, especially risperidone, can represent a reasonable first-line option because of the low propensity for drug–drug interactions and the low risk of seizures. Quetiapine is burdened by a clinically significant pharmacokinetic interaction with enzyme-inducing drugs leading to undetectable levels of the antipsychotic, even for dosages up to 700 mg per day.

Summary Purpose:  Depression is an important but underdiagnosed complication of epilepsy. This study compares potentially suitable screening tools head‐to‐head. Methods:  We enrolled 266 attendees with a confirmed diagnosis of epilepsy at a specialized neurologic epilepsy service in London and compared verbal self‐report and visual analog (VAS) screening methods for depression. These included two generic depression scales (Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory II [BDI‐II]), one epilepsy specific scale (Neurological Disorders Depression Inventory for Epilepsy [NDDI‐E]) and one new visual‐analog scale (Emotional Thermometers [ET]). We used Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) criteria for major depression and International Classification of Diseases, Tenth Revision (ICD‐10) criteria for depressive episode as the reference standard. Key Findings:  Against ICD‐10–defined depression the most accurate scales by receiver operating characteristic (ROC) curve area were HADS Total (HADS‐T, 0.924), BDI‐II (0.898) and NDDI‐E (0.897). New visual‐analog methods had similar accuracy measured either in combination or individually. Although no test performed well in a case‐finding role, several performed well as a rule‐out initial step, owing to high negative predictive value and specificity. In this role, the optimal performing conventional tools were the HADS depression subsscale (HADS‐D) and the NDDI‐E and the optimal single VAS were the depression thermometer (DepT) and the distress thermometer (DT). Against DSM‐IV– defined major depression, results were similar with optimal performance by the HADS‐T, BDI‐II, and NDDI‐E, but here the anxiety thermometer (AnxT) as well as DepT and DT also offered good performance. Given that no test performed well in a case‐finding role, we suggest that these tests are used as an initial first step to rule out patients who are unlikely to have depression. Significance:  We suggest that the six‐item NDDI‐E or seven‐item HADS‐D should be considered if a conventional scale is preferred and that the revised ET4 be considered if a visual‐analog method is required. Follow‐up examination and intervention, where indicated, are necessary in all those who screen positive on any measure as these are not intended as diagnostic tools.

We suggest that aripiprazole may well be useful for individuals with TS as response to it is often quick, dramatic, sustained and with few generally mild and transient side effects.