Neuropsychiatry

These presentations may include anxiety, depression and psychosis occurring in the context of epilepsy, parkinson’s, multiple sclerosis, encephalitis and other neurological diseases.

We provide:

• Outpatient clinics for general and specialised Neuropsychiatric presentations
• Inpatient admissions to Hughlings Jackson ward, a tertiary referral unit.
• Consultation-liaison neuropsychiatric service for inpatients admitted to neurological, neurosurgical and neuro critical care beds at NHNN. 
• Our approaches include: neuropsychiatric, pharmacological, psychological (primarily cognitive behavioural therapy), occupational therapy, specialised physiotherapy and care from a core experienced team of dually trained nurses in both mental and physical health.

Functional neurological symptom disorder encompasses symptoms seemingly manifested through the neurological system but which are not caused by a physical neurological disease.

We view the mind and body as working in an integrated way which is reflected in our treatment approach.

Neuropsychiatry is ideally placed at the interface of Neurology and Psychiatry to create and deliver treatment programmes which integrate physical, behavioural and psychological factors relevant to the development of FNSD.

We look at both the symptoms and the narrative around symptoms which are important elements in the causation of the disorder. We look at precipitants and triggers to symptoms and perpetuating factors that may maintain them. We aim to address both. Sometimes, predisposing factors are important and our approach may raise awareness of the role these may play. Where co-morbid conditions play a prominent role, we may make suggestions as to how these could be explored.

The aim of our approach is to provide education and therapies which facilitate self-management. Individuals are guided to better understand their symptoms and to develop their own skills to manage, reduce and eventually in some cases, resolve them.

At present the approaches we use initially involve a combination of consultation and education. Further approaches include cognitive behavioural therapy, occupational therapy, physiotherapy focused on movement re-training and nursing interventions. These may be delivered remotely, face to face, in groups, in individualised multidisciplinary programmes within outpatient settings or inpatient environments. 

Therapies

For referrals that are accepted, patients will be reviewed in a Multi-Disciplinary Team (MDT) assessment clinic. This is to consider what approach may best suit an individual. We run education seminars to improve insight and understanding into FNSD. We also provide outpatient cognitive behavioural therapy and multidisciplinary programmes that combine cognitive behavioural therapy, occupational therapy, physiotherapy including for movement re-training, nursing and psychiatry.

How to make a referral for FND

We accept referrals where:

• A diagnosis of FNSD has been made by a neurologist
• The individual understands and accepts the diagnosis following explanation.
• The individual is seeking and ready to engage with treatment with a view to making changes
• Treatment locally has been sought including through physical and psychological therapies
• Where individuals have been previously treated, please provide treatment details and outcomes.

Further information which may help facilitate a discussion around the diagnosis and symptoms can be found at: www.neurosymptoms.org

We are a tertiary service and would recommend the attempts are made to treat and address issues locally in the first instance. Where patients have been previously treated, please provide details of treatment details to date and outcomes.

We are less likely to accept referrals on to active treatment pathways where:

• An individual is already in assessment or treatment for FNSD by another service at the point of referral.
• Chronic fatigue is a primary / predominant issue which could be addressed in a specialist service in the first instance.
• Pain is a primary / predominant issue which could be addressed in a specialist pain service in the first instance.
• High dose sedative medication of a degree which may impair ability to engage with treatment.
• Individuals may not be open, able or ready to use a psychologically minded approach.

The National Tourette Syndrome service is based at the National Hospital for Neurology and Neurosurgery (NHNN). We offer assessment, advice and treatment to patients with a suspected or confirmed diagnosis of Tourette syndrome. It is led by Eileen Joyce, consultant neuropsychiatrist and professor of neuropsychiatry at the UCL Queen Square Institute of Neurology. We are a research focused clinical service, with our clinicians embedded within the wider Tourette Syndrome Research Group at the Department of Clinical and Movement Neurosciences at UCL Institute of Neurology.

The clinical service includes two consultant neuropsychiatrists running an outpatient service divided into two streams as follows:

1. Outpatient clinic for Tourette syndrome in Adults (General Stream)

1. Outpatient clinic for Tourette syndrome in Adults comorbid with Obsessive Compulsive Disorder (OCD stream)

In addition the service is supported by a number of CBT therapists who are able to provide Cognitive Behavioural Interventions for Tics (CBIT), including habit reversal therapy, to patients who meet the feasibility criteria as established by one of our consultant neuropsychiatrists and are unable to access such therapy in their local area. Our service can manage neurologically complex presentations within NHNN in close collaboration with other neurologists and neurosurgeons. There is also a provision to consider and provide Botulinum toxin treatment for tics where appropriate.

If a diagnosis of Tourette syndrome is confirmed on assessment, patients are offered a choice between appropriate treatments for their condition and they typically stay under the care of the clinic for more than a year. All treatments are delivered under shared care agreements with local services. 

Our service has close links with academics working at the UCL Queen Square Institute of Neurology and patients may be invited to participate in research studies of Tourette’s syndrome. 

About Tourette syndrome in adults

Tourette syndrome (abbreviated as TS or Tourette's; also known as Gilles de la Tourette syndrome) is a neuropsychiatric disorder with onset usually occurring before the age of 18. It is characterised by repeated involuntary movements (motor tics) and uncontrollable noises (phonic tics). Common tics are throat-clearing and blinking but more complex movements or repetition of words, rarely with swear words, can be seen. About one of every 100 people has Tourette syndrome. It is more common in boys than girls. The tics usually start in childhood and may be worst in the early teens. It often occurs with other problems, such as attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety and depression. Not all tics indicate Tourette syndrome.

The cause of Tourette syndrome is unknown, but it is considered to be related to alterations in dopamine neurotransmission in the movement areas of the brain. For a diagnosis of Tourette syndrome, both multiple motor and one or more phonic tics need to be present with tics occurring many times a day, nearly daily, over a period of more than one year. If motor or phonic tics occur alone this is referred to as a chronic motor or phonic tic disorder but is manged in the same way. No treatment is needed unless the tics interfere with everyday life. In clinically significant cases it is frequently a cause of marked distress or significant impairment in social, occupational, or other important areas of functioning. Although there's no cure for Tourette syndrome, effective treatments are available and require comprehensive management which may include medication, cognitive-behavioural therapy and other approaches.

Recent research suggests that tics persist in a significant proportion of patient beyond childhood. Cases of Tourette syndrome in adults, especially those with mild tics and/or severe comorbidities like OCD, mood disorders and other movement disorders often go unrecognised and preclude adequate treatment. Our service focuses on the comprehensive assessment and management of Tourette syndrome and tic disorders in 18 year olds and above. We are also able to consider referrals of 16-18 year olds on a case by case basis.

More information:

• https://www.nhs.uk/conditions/tics/treatment/
• https://www.tourettes-action.org.uk/