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ObjectivesChanges in the severity of tics in Tourettes syndrome (TS), as seen with variations in the intensity or frequency of tics, can be moderated by a variety of independent simple or complex factors suchasexternalorinternalstimulioverlaidwithpsychologicalandphysiological variables. Identifying such moderators has important clinical implications as it can aid clinicians in adjusting interventions. Here we review research literature related to tic-severity moderators and their tic-worsening, tic-improving and neutral effects in individuals with TS with the aim to create a clinical inventory of moderating variables.MethodsA literature search using terms relating to tic severity, tic frequency, factors and moderators was conducted on Ovid Medline, Psych Info, APA Psych Articles, ProQuest,Scopus and PubMed following PRISMA guidelines. The criteria for this review included any published study, review and meta-analysis after the last review in 2008, investigating external and internal factors that had a tic-worsening, improving or neutral effect on children, adolescents or adults with TS and comorbidities.Results225 studies were initially identified after deduplication. A variety of tic severity moderators were identified with the most prominent being the effects of exe, sleep, distraction and comorbidities such as ADHD. However, an interesting finding was the high variability in these tic-moderating effects, as the same factor was tic-worsening in some patients and tic-improving in others, highlighting the subjectivity of these effects on tic severity. It was also noted that most of there viewed research did not report the possibility of a neutral effect.ConclusionsAs previous research has looked at these moderators in a dichotomous way, clinicians and researchers should be made more aware of the existence and variability of these tic severity moderators and of their highly subjective effects. This also has important, direct implications for the psychological assessment and treatment of tics. This review invites future research and clinicians to take this holistic approach on the effects ontic severity into consideration.

IntroductionPost-stroke anxiety (PSA) is hugely under-diagnosed (Rafsten, Danielsson, &Sunnerhagen, 2018). As it can have a significant negative impact on both short- and long-term clinical outcomes, it is essential to have an accurate screening measure specific to stroke populations. While a considerable number of anxiety-screening instruments have been developed, there is wide variation in their applicability when used after stroke. The heterogeneity across these measures produces challenges for clinicians when selecting a reliable and valid measure for PSA.AimThe purpose of this review is to identify tools that have been used to screen for anxiety after stroke and to systematically review their usefulness and validity in this population.MethodThe literature on PSA was reviewed until 1969 using Medline (OVID version), PsychINFO and PubMed databases. Literature searches were conducted using the following keywords in multiple combinations: Post, stroke, anxiety, assessment, screening, tool, measure. Additionally, the literature search included reference lists in publications that measured anxiety in stroke populations and articles that reported the development and psychometric properties of instruments designed to measure PSA. Publications reporting measures assessing specific anxiety subtypes were excluded. All measures were reviewed individually with emphasis on the population demographic they were initially developed for, anxiety subtype they were most sensitive to, the psychometric data and advantages and disadvantages relevant to each measure.ResultsA review of the articles reporting the following six measures of anxiety was conducted i.e. The Adult Manifest Anxiety Scale, the Beck Anxiety Inventory, the Behavioural Outcomes of Anxiety scale (BOA), the Geriatric Anxiety Inventory (GAI), the Hamilton Anxiety Rating Scale and the Hospital Anxiety and Depression Scale.Preliminary data indicated that while the clinical utility of all the screening tools with regards to case-finding was tolerable, the BOA and the GAI were viewed as the most satisfactory tools for screening PSA.ConclusionsWhile there are several existing screening tools for anxiety, they do not show potential as suitable measures in stroke populations. Preliminary data suggests that although they are not without limitations, the GAI and the BOA serve as adequate measures of anxiety in stroke populations. Overall the literature review suggested an unmet need to develop an anxiety screening measure specifically for this population.ReferenceRafsten L, Danielsson A, Sunnerhagen KS. Anxiety after stroke: a systematic review and meta-analysis. Journal of Rehabilitation Medicine2018;50:769–778. https://doi.org/10.2340/16501977-2384

ObjectivesBehavioural Initiation is defined as the innate ability to trigger action. There is rich literature describing the high prevalence of motivational disorders and poor behavioural initiation during rehabilitation following acquired brain injury. This is not only due to their neurological conditions, but also that they might have spent many weeks in the wrong environment, with no stimulation other than receiving essential care. There is no established measure for behaviour initiation specific for a rehabilitation setting. This project aim to develop a tool that is sensitive to patients’ level of behavioural initiation, and support evidence-based decision making in formulating treatments in the Multi-Disciplinary Teams (MDT).MethodsWe proposed the 10-item nurse-rated Behavioural Initiation Rating Scale (BIRS). BIRS items were tailored to measure patient behaviour in day-to-day scenarios in inpatient rehabilitation. Included statements were shortlisted from a large pool of comments and observations from the MDT, and a review of literature on the topic. Following basic training with the nursing staff, we piloted a feasibility trial of BIRS for 4 weeks at an 18-bed Neurorehabilitation Unit. We arranged two focus-groups with MDT therapists and the nursing team, to reflect on the implementation of BIRS, and further refinement of scale items. Opinions from the focus-groups were used to revise the current version of BIRS.ResultsIt takes less than 2 minutes to administer and score BIRS. BIRS appears to be sensitive to improvement in behavioural initiation, and in agreement with clinical impressions from MDT and feedback from carers. BIRS has been well-implemented into routine practice, and has resulted a cultural shift in the unit. We identified some levels of between-rating variation in using BIRS, which was addressed by clarifying the instruction manual and giving specific examples for the ambiguous items.Secondary to our aim, the implementation of BIRS has improved the communication between nursing staff and therapists in delivering cohesive neurorehabilitation.ConclusionsBIRS appears to be a promising tool to evaluate patient behavioural initiation in a rehabilitation setting. A multi-centre trial of BIRS is currently being planned to establish its psychometric properties.

Objectives/AimsCapgras syndrome is not often seen in neuro-rehabilitation and few case-reports of Capgras syndrome after anti-NMDA receptor encephalitis exist in literature. This case is relevant in light of how the Capgras sydrome and delusional beliefs affected this patient’s discharge planning, engagement with the multi- disciplinary team during rehabilitation and side-effects of pharmacological management. The challenging aspects of the case revolve around the patient’s persecutory beliefs, his delusional misidentifation disorder and its subsequent management.MethodsThe patient is a middle-aged gentleman with a background of relapsing- remitting multiple sclerosis who presented with seizures, headache, rash and intermittent fevers. He was initially treated as infectious meningoencephalitis and his condition deteriorated due to combination of behavioural change and seizures. A MRI-head suggested viral encephalitis but lumbar puncture and serum showed strongly positive for anti-NMDA receptor antibodies, thought potentially secondary to the patient’s disease-modifying drugs for his multiple sclerosis. After step-down from Intensive Care, the patient was noted to have fixed persecutory delusions regarding his wife and children. He believed that his wife and children were imposters and that the hospital and doctors within it were conspiring against him. He was managed initially with risperidone however the dose could not be increased due to the sedating side-effects resulting in an inability to engage with rehabilitation. He was subsequently changed to aripiprazole and escitalopram with the intention to decrease his delusional misidentification disorder. His delusions partially resolved with the patient accepting his children as his own, but not accepting his wife as truly ‘his wife’. The discharge destination represented a difficulty due to concerns that he may become aggressive (physically/verbally) to his wife if he continued to deem her an ‘imposter’. The patient was managed by sidestepping the conflict; he was more accepting of his wife if introduced as a ‘friend who loves him’. The patient was also allowed to drive the narrative rather than forced to deal with his Capgras syndrome. Results: A discharge home with support (including his wife) became feasible as his delusion thawed.ConclusionsManaging complicated patients like this involves not only pharmacological options but also psychological/psychiatric intervention and employment of non-confrontational techniques to help better engagement with rehabilitation.

Consistent with the NHS quality agenda, Dept. of Health, 20111there has been a drive to routinely incorporate outcome and performance measurement data in clinical practice. An absolute requirement within NHS services2are Patient-Rated Outcome Measures (PROMS) which are used by some Royal College of Psychiatry faculties to quantify outcomes, improve accountability, performance management and service. They can also be used to screen for common health problems and ensure the comprehensive assessment of complex Acquired Brain Injury (ABI) Patients who typically present with various neurological and psychiatric comorbidities.The North Bristol NHS Trust Outpatient Clinic at The Frenchay Brain Injury Rehabilitation Centre and The Rosa Burden, Southmead Hospital, conducts new assessments and regular patient reviews for referrals from South West England. As part of a quality improvement initiative a semi-structured process of assessment was trialled, to improve patient experience by providing a comprehensive initial assessment, improving treatment productivity and reducing over-running clinics.MethodReferrals were audited and common reasons for referrals identified. Questionnaires and tools used in the clinic were reviewed and those most frequently used were compiled. The evidence for questionnaires utilized for different psychiatric comorbidities and applicability in ABI was examined in the literature. The finalized patient questionnaires booklet section and their sequence was decided based on expert peer recommendations and patient feedback. The collateral section was similarly developed with some questionnaires modified for operational reasons.SECTION ONE: SELF RATED PRE-ASSESSMENT QUESTIONNAIRERivermead Post Concussion Symptoms Questionnaire, Patient Health Questionnaire (15): Somatic Screen, Patient Health Questionnaire-9: Depression screen, General Anxiety Disorder 7: Anxiety screen, Mood Disorder Questionnaire: Bipolar Affective Disorder screen and the Civilian Version PTSD Checklist.SECTION TWO: CARER/FAMILY PRE-ASSESSMENT QUESTIONNAIREModified Overt Aggression Scalescreen for aggression, Neuropsychiatry Inventory Questionnaire: assesses psychiatric symptoms in patients with neurological disordersOutcomeThe final booklet was divided into three sections:Patient-Rated, ObserverRated and Clinician Section. Consultation efficiency was improved with the Patient and Observer rated sections completed prior to the initial assessment. The checklist is used for all initial assessments with good uptake and allowed for standardization of clinical information gathering. PROMs for mood are collected at each clinic appointment with other domains repeated if abnormal at initial clinic assessment or clinically relevant.ReferencesFossey M, Parsonage M. Outcomes and performance in liaison psychiatry: developing a measurement framework. Centre for Mental Health and Royal College of Psychiatrists ReportJune 2014.Trigwell P, Kustow J, Santhouse A, et al. Framework for routine outcome measurement in liaison psychiatry (FROM-LP): faculty of liaison psychiatry royal college of psychiatrists faculty report. The Royal College of Psychiatrists2015.vretveit J, Zubkoff L, Nelson EC, et al. Using patient-reported outcome measurement to improve patient care. Int J Qual Health Care 2017 Oct 1;29(6):874879.

Objectives/AimsObsessive-Compulsive Disorder (OCD) is a common neuropsychiatric condition characterised by persistent endogenous repetitive and intrusive anxiogenic thoughts, feelings, or images often followed by anxiolytic mental or physical actions. Serotonin reuptake inhibitors (SRIs) are the mainstay of OCD treatment, used both as first line (SSRIs) and second line (Clomipramine) approaches. Despite their effectiveness in treatment of OCD, their anti-obsessive effects only start at eight to 12 weeks into treatment (Pittenger & Bloch, 2014), leaving an effectiveness time gap between diagnosis and treatment. Various treatment strategies have been tried but there is no consensus on the most effective approach. A single pharmacological agent with rapid anti-obsessive action would be an ideal candidate to manage this treatment gap. One such agent may be ketamine with its novel mechanism of action.Ketamine is assumed to increase neuroplasticity by synthesising neurotrophins in the cortex and has demonstrated to have rapid-onset anti-depressant effects (Bjrkholm & Monteggia, 2016). We reviewed the state of evidence for similar rapidly emerging anti- obsessive effects and report our findings here.MethodsEmbase, MEDLINE(R), and PsycINFO were searched to identify studies investigating rapid anti-obsessive effects of ketamine in humans, available in English. ClinicalTrials.org was further searched for grey literature. Other reviews were excluded.Results181 studies were identified after deduplication of which nine studies met inclusion criteria. Eight studies revealed rapid anti-obsessive effects, five of which display statistical significance. Combined, OCD scores decline by approximately 49.7% during the first hour following intravenous ketamine administration. Furthermore, a significant reduction of depressive symptoms and suicidality were reported in studies further investigating comorbid depression. Contrary to depression scores, anti-obsessive effects were not sustained. OCD scores increased within three hours post-administration and reversed back to baseline within seven days. One trial reported an extended length and margin of effect when combined with cognitive behavioural therapy.All studies were of small scale as the literature search primarily yielded pilot trials and case reports, suggesting statistical imprecision and reflecting the topics novelty.ConclusionsOur review points out the presence of preliminary research evidence to support the presence of anti-obsessive effects of ketamine and a potential for its usefulness as a rapidly acting intervention for OCD, thereby plugging an important gap in clinical management of OCD. However, as such effects are unsustained, their potential to complement existing pharmacological strategies may be limited.Greater awareness and randomised controlled trials are required before recommending the use of ketamine in OCD treatment.ReferencesBjrkholm C, Monteggia LM. BDNF a key transducer of antidepressant effects. Neuropharmacology 2016;102. doi:10.1016/j.neuropharm.2015.10.034Pittenger C, Bloch MH. Pharmacological treatment of obsessive-compulsive disorder. The Psychiatric clinics of North America 2014;37(3):375391. doi:10.1016/j.psc.2014.05.006

IntroductionTourette Syndrome (TS) is a prototypical Neuropsychiatric neurodevelopmental disorder consisting of multiple motor tics and at least one vocal tic, usually preceding the motor tic, with onset prior to age 18 and of a duration of at least 1 year.1 2It is estimated that 50% of TS patients demonstrate OCD behaviours during their lifetime.3Selective Serotonin Reuptake Inhibitors (SSRI’s) are approved for treatment of depression and for OCD. There are literature reports of the SSRIs, exacerbating or causing tics. However, in all the cases described, symptoms resolved on cessation of Sertraline. We present below a case report of a patient in which this was not the case.Case ReportOur patient was a 22-year-old man an unremarkable medical and psychiatric history except mild childhood tics, resolved in adulthood, was referred with a 3-year history of disabling tics (vocal and motor) of sudden onset after using Sertraline prescribed for depression. Three days post Sertraline he began singing his conversation, swearing and suffering from muscle twitches. His symptoms evolved to include: facial tics (masseter spasms, blinking, puffing of his cheek, expelling air through his lips, forehead wrinkling), complex thoracic and upper limb tics (violent head turnings with a hand grabbing motion, shrugging shoulders with violent right arm movements imitating a severe precordial thump, upper limb shaking with spasms and episodes of punching outwards and upper limb flexion with fingers curled as if he is holding an object such as a gun), Lower limb tics (hip gyration, kicking and occasional foot tapping) and vocal tics (simple and complex). Tics were associated with premonitory urge with increased anxiety and intensity on voluntary inhibition. Investigations were unremarkable and included an LP, blood tests with immunological profile, photo stimulation EEG and an MRI. Unsuccessful treatment modalities employed: CBT for twitches (24 sessions) and psychopharmacological interventions (Risperidone, Haloperidol and Quetiapine. Family history was significant for Sertraline intolerance. He was treated with Aripiprazole 2.5 mg for his diagnosis of Gilles la Tourette syndrome with comorbid OCD.ResultsThe subject responded well to Aripiprazole with reduced tic episodes.ConclusionThe above case is the only one in the literature to identify a family history of sertraline intolerance and requiring treatment with D2 modulator and a 5HT agonist for tic cessation after tic exacerbation post Sertraline treatment.ReferencesRobertson MM, Eapen V. Cavanna AE, et.al. The international prevalence, epidemiology and clinical phenology of Tourette Syndrome: a cross cultural perspective. J Psychosom Res2009; 67(6): 475–83American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th Edition. Arlington (VA): American Psychiatric Association, 2013Leckman JF, Pauls DL, Cohen DJ. Tic disorders. In: Bloom FE, Kupfer DJ. (eds). Psychopharmacology: The fourth Generation of Progress. New York: Raven Press, 1995, 1665–1674

IntroductionAuditory verbal hallucinations (AVH): the ‘subjective experience of hearing voices speaking in the absence of corresponding physical stimulation’ (Kompus et al 2013) are part of Schneider’s first rank symptoms. They are included in the American Psychiatric Association DSM-5 diagnostic criteria for Schizophrenia and can be difficult to treat in a proportion of patients with drug resistance in up to 25% of casesCaseOur case is a 52 year old gentleman with a background of treatment resistant schizophrenia, who presented to hospital with a right sided hemiplegia and aphasia. He was diagnosed with a left middle cerebral artery territory stroke. A post CVA MRI showed ‘an extensive mature infarct in the left middle cerebral artery territory and encompassed the left superior temporal gyrus (STG) where the primary auditory cortex (PAC) is located’. He was known to a mental health team from 1989 and had eight inpatient psychiatric admissions, under section, with thought disorder and paranoid thoughts with aggressive behaviour endangering himself and the public.Prior to the stroke he was treated with monthly Pipothiozine Depot Injections, however, these were missed post stroke; he remained untreated for his paranoid schizophrenia and no signs of distress or paranoia were identified by any of the treating staff. Due to his speech impairments, his mental state remained difficult to assess, however, in conjunction with speech and language colleagues the Neuropsychiatrist ascertained that there was no evidence of psychosis, beliefs or behaviours similar to his pre-morbid mental state.DiscussionThe human PAC is part of the temporal lobe and is the final target for afferent auditory signals. It is found bilaterally, specifically within the STG, occupying the dorsal and lateral surface of the STG and encompassing Heschl’s gyrus. There are several different hypotheses regarding the neural mechanisms behind auditory verbal hallucinations. Multiple studies have implicated the primary auditory cortex as being central to this process and functional imaging has shown the STG to be activated in patients with schizophrenia during hallucinations. The resolution of symptoms in this case supports the involvement of the PAC in AVH and could represent a target for future therapies.

ObjectivesApathy has been associated with frontal-subcortical pathway impairments. However, presentation of apathy and its subtypes (e.g. behavioural, cognitive, executive, social) differs amongst neurological and psychiatric disorders. Our review focused on the neuroanatomy of apathy following acquired brain injury (stroke and traumatic brain injury (TBI)), with an aim to identify unique and shared neural networks underlying apathy presentation in different disorders. We aim to demonstrate a visual overview of the identified locations, types of lesion and neural pathways associated with apathy.MethodsWe explored peer-reviewed literature from Web of Science, PubMed and Psychinfo. Imaging studies looking at the association between brain lesion location and apathy symptoms in post-stroke or TBI patients were reviewed. A series of brain images would be used to depict the neural network of motivation in a healthy brain versus an apathetic brain. Identified regions of impairments related to apathy would be presented separately for TBI and stroke patients. We would further describe the association between stroke types and apathy.ResultsMRI studies consistently show that apathy appears related to impairments at the frontal-subcortical circuit. Apathy appeared to be more prevalent following lacunar stroke, with lesions at subcortical areas such as the pons and anterior cingulate cortex. Rate of apathy appears to be similar across ischemic and haemorrhagic stroke. Previous reviews did not identify an association between stroke volume with post-stroke apathy. Recent research explored the relationship between white matter microstructure reduction with post-stroke apathy without identifying any specific correlation with lesion locations.ConclusionsPost-TBI apathy is highly prevalent yet under-researched. Evidence regarding the location of lesions was less consistent for post-stroke apathy. Due to the widespread use of apathy scales that do not specify subtypes, the current review could not speculate the relationship between brain injury with specific apathy subtype presentations. Null finding in previous reviews regarding lesion size and location could be potentially attributed to the poor differentiation amongst apathy subtypes.

ObjectiveObsessive compulsive disorder (OCD) has a lifetime prevalence of 1%–2%. Standard treatments are ineffective in up to 40% of cases. Even with the best treatments, there remains a subgroup with severe symptoms and significant disability. Studies of deep brain stimulation (DBS) for OCD have shown improvement in both symptoms and quality of life in severe OCD. Two targets in particular have shown promise: the anteromedial subthalamic nucleus (STN) and the ventral capsule/ventral striatum (VC/VS).1–3It is not clear however if one site has advantages over the other and, with regard to the VC/VS site, whether stimulation of the anterior capsule white matter or ventral striatum/nucleus accumbens grey matter is critical for improvement.2,3We report a within subject comparison of the effect of DBS on OCD symptoms at STN and VC/VS sites both individually and together (ClinicalTrials.gov #NCT02655926). The aims of the study were to determine: a) the efficacy of DBS at each site; b) whether stimulation of both sites improves the response compared to either site alone; and c) the critical stimulation contacts at the VC/VS site.MethodSix participants, with severe treatment refractory OCD, were recruited via the UK specialist OCD service and underwent implantation of bilateral electrodes at both the VC/VS and anteromedial STN sites. A Leksell frame-based MRI-guided and MRI-verified approach under general anaesthesia was used. The subthalamic nucleus was localised on axial T2-weighted stereotactic images and the VC/VS localised on coronal and axial proton density images (Siemens, 1.5T). Using a double blind cross-over design, 12 weeks stimulation at STN and VC/VS sites was compared, followed by stimulation at both sites for 12 weeks. The primary outcome measure was YBOCS: an improvement of greater than or equal to 35% was the predefined response.ResultsAccurate stereotactic and anatomical lead location was confirmed on immediate postoperative stereotactic MR images in all patients. For the VC/VS target, the deepest DBS lead contact was within the nucleus accumbens, the one superior to that in the “shell” of the nucleus accumbens while the superior two contacts were within the inferior aspect of the anterior limb of the internal capsule. The response rates (defined as the number of patients with >35% reduction in YBOCS) were: STN 3/6; VC/VS: 5/6; STN + VC/VS: 5/6. In the one non-responder YBOCS reduction was 32% after the combined STN+VC/VS stimulation phase. For the whole group, the mean reduction in YBOCS scores were: STN 16.3; VC/VS: 19.2; STN + VC/VS: 22.0 which represents a mean reduction of 42%, 53%, 62% from their own baseline scores and a reduction to predefined mild/subclinical symptoms of 0%, 50% 50% respectively. The top two DBS contacts of the quadripolar lead were found to be the most effective at the VC/VS target in all 6 patients.ConclusionsThese results suggest that:a) The VC/VS site may be superior to the STN site for the amelioration of severe OCD symptoms; b) There is only a modest advantage of stimulating both sites together; and c) The effective stimulation site for the VC/VS target is the inferior aspect of the anterior limb of the internal capsule and not the ventral striatum/nucleus accumbens grey matter.Additional InfoThe study was funded by the MRC (MR/J012009/1).References. Mallet, et al. N Eng J Med2008;359:2121.. Denys, et al. Arch Gen Psychiatry2010;6:1061.. Greenberg, et al. Molecular Psychiatry2010;15:64.