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A Case of Functional Neurological Disorder With Cognitive Symptoms: Emotion-Focused Psychotherapeutic Insights
... Three studies involved more than 100 subjects/participants in the cohort receiving some form of telerehabilitation [44][45][46]. Eight studies involved either a small number of subjects/participants (range: 1-32) engaging in some form of telerehabilitation [16,29,[47][48][49][50][51] or a limited number of telerehabilitation sessions, such as the study by Sharpe et al. (2011), which included only five telerehabilitation sessions [43]. All, except for one study on veterans [50], included more females than males as participants. ...
... All, except for one study on veterans [50], included more females than males as participants. The mean age of subjects/participants who engaged in telerehabilitation ranged from 36.4 [46] to 59 [48] years. Regarding FND subtypes, most studies focused on mixed/various/unspecified FNDs (n = 4) [43][44][45]51], functional seizures (n = 3) [46,49,50], and functional movement disorders (FMDs) (n = 2) [16,29]. ...
... Regarding FND subtypes, most studies focused on mixed/various/unspecified FNDs (n = 4) [43][44][45]51], functional seizures (n = 3) [46,49,50], and functional movement disorders (FMDs) (n = 2) [16,29]. Therapy delivered via telerehabilitation (i.e., remotely using some form of technology) included cognitive behavioural therapy (CBT) [43,45,46,49,51], Neuro-Behavioural therapy (NBT, or CBT-informed psychotherapy) [44,50], physiotherapy [16,29], emotion-focused psychotherapy [48], and speech and language therapy (SLT) [47]. Telerehabilitation providers included psychologists in five studies [43][44][45]49,51], neuropsychiatrists in three studies [43,49,50], psychiatrists in three studies [29,45,51], physiotherapists in two studies [16,29], occupational therapists in two studies [45,51], a nurse in one study [43], and a speech-language pathologist in one study [47]. ...
... FCD is also overrepresented in primary care, and in populations with other functional neurological disorders(3), post-mild traumatic brain injuries (4), and other systemic conditions. Excessive attention towards the self and cognitive processes (2), health anxiety about cognition, memory perfectionism (5), obsessive thought structures, neuroticism (6), poor global metacognition (7,8), and abnormal emotional processing (7,9) have been hypothesised as potential mechanisms for the symptoms (10). ...
... Preliminary evidence for functional memory symptoms suggests that psychotherapy targeting negative memory beliefs and stress regulation (17) is potentially beneficial, but findings were inconclusive and need replication (18). Imported therapies from other functional disorders, including cognitive-behaviouraltherapy (CBT), have been tried in practice but have yet to be rigorously investigated (9,(19)(20)(21)(22). Also, while potentially effective, face-to-face interventions are limited by restricted expertise, heterogeneous framing of symptoms (23), cost, and stigma (24). ...
Background:
Functional cognitive disorder (FCD) is a common and disabling condition for which accessible and evidence-based treatments are urgently needed.
Objective:
We describe the planning and development stages of a new self-help mobile app intervention for FCD.
Methods:
The UK Medical Research Council's Complex Interventions framework was followed. Theory- and user-centered approaches were adopted to develop Mementum – a 6-week programme rooted on cognitive behavioural techniques and complementary principles (mindfulness, education, cognitive rehabilitation).
Results:
A scoping review is presented. Thematic analysis of patient interviews identified 6 themes and 13 subthemes, including user needs, management strategies, opportunity and motivation. The treatment model places attentional dysregulation as the core symptom generator, around which treatment content was developed. Provisional insights from a focus group suggested the intervention is acceptable and credible. Facilitators and barriers were uncovered and addressed. The programme includes 7 modules, videos, patient stories, FAQs, and signposting to existing resources. Interactive features include a weekly memory diary and symptom checklist, tailoring of contents to symptoms, and homework tasks.
Conclusions:
We used a systematic approach to develop a novel digital health intervention for FCD. Collaborations with key stakeholders enabled intervention development and optimisation. Feasibility, acceptability, and efficacy testing of this intervention are underway.
... There has been very little work on this issue to date, with the exception of isolated case studies. 26 On the basis of the current results, maximal benefit might be achieved with a cognitive rehabilitation approach that addresses all primary domains, with a focus on attention and processing speed, which, if ameliorated, might lead to downstream improvements in other areas. Importantly, there are good reasons to design a novel intervention to account for the core symptoms of functional seizures (eg, seizures and somatization) 4 and to acknowledge the unique life experiences of these patients (eg, stigma and discrimination) 27 in a combined cognitive-psychological approach, rather than merely borrowing content directly from previous treatment protocols. ...
Background
Cognition is a core component of functional seizures, but the literature on cognition in this disorder has been heterogeneous, with no clear unifying profile emerging from individual studies. The aim of this study was to do a systematic review and meta-analysis of cognitive performance in adults with functional seizures compared with epilepsy (including left temporal lobe epilepsy) and compared with healthy non-seizure cohorts.
Methods
In this systematic review and meta-analysis, starting Feb 6, 2023, replicated and updated on Oct 31, 2023, a medical librarian searched MEDLINE, Embase, PsycINFO, and Web of Science. Inclusion criteria were full reports documenting raw or standardised cognitive test data in adults with functional seizures compared with adults with epilepsy, prospectively recruited healthy comparisons, or published norms. Grey literature was retained and there were no language or date restrictions. We excluded studies only reporting on mixed functional seizures and epilepsy,
or mixed functional neurological samples, with no pure functional seizures group. Risk of bias was evaluated using a modified version of the Newcastle–Ottawa Scale. People with lived experiences were not involved in the design or execution of this study. This study is registered as CRD42023392385 in PROSPERO.
Findings
Of 3834 records initially identified, 84 articles were retained, including 8654 participants (functional seizures 4193, epilepsy 3638, and healthy comparisons 823). Mean age was 36 years (SD 12) for functional seizures, 36 years (12) for epilepsy, and 34 years (10) for healthy comparisons, and the proportion of women per group was 72% (range 18–100) for functional seizures, 59% (range 15–100) for epilepsy, and 69% (range 34–100) for healthy comparisons. Data on race or ethnicity were rarely reported in the individual studies. Risk of bias was moderate.
Cognitive performance was better in people with functional seizures than those with epilepsy (Hedges’ g=0·17 [95% CI 0·10–0·25)], p<0·0001), with moderate-to-high heterogeneity (Q[56]=128·91, p=0·0001, I²=57%). The functional seizures group performed better than the epilepsy group on global cognition and intelligence quotient (g=0·15 [0·02–0·28], p=0·022) and language (g=0·28 [0·14–0·43], p=0·0001), but not other cognitive domains. A larger effect was noted in language tests when comparing functional seizures with left temporal lobe epilepsy (k=5; g=0·51 [0·10 to 0·91], p=0·015). The functional seizures group underperformed relative to healthy comparisons (g=−0·61 [−0·78 to −0·44], p<0·0001), with significant differences in all cognitive domains. Meta regressions examining effects
of multiple covariates on global cognition were not significant.
Interpretation
Patients with functional seizures have widespread cognitive impairments that are likely to be clinically meaningful on the basis of moderate effect sizes in multiple domains. These deficits might be slightly less severe than those seen in many patients with epilepsy but nevertheless argue for consideration of clinical assessment and treatment.
... • Implementation of evidence-based psychotherapeutic interventions focused on FNSD symptoms and relevant contributing factors (LaFrance Jr et al., 2020;Millstein et al., 2023). ...
Objective: Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists.
Methods: A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment.
Results: Two primary areas of focus for this review are the following: (1) increasing neuropsychologists' training in FNSDs, and (2) increasing neuropsychologists' role in assessment and treatment of FNSD patients.
Conclusions: Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.
... She became more tearful and then cried for several minutes. 13 During this time, her shoulders and chest visibly relaxed. Afterward, we used a metacognitive process to assess how her arousal appeared as a defense against an overwhelming experience. ...
Background
Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions.
Methods
International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter‐rater agreement analyses were undertaken.
Results
Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%–88% of the FCD diagnoses were attributed to non‐neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%–92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD.
Conclusions
Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence‐based interventions.
Functional neurological disorder (FND) reflects impairments in brain networks leading to distressing motor, sensory, and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of FND has been the mechanistic and etiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g., allostasis, predictive processing, interoception, and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of FND and related functional somatic symptoms. In doing so, we address several themes for the FND field including: 1) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, “panic attack without panic”, dissociation, insecure attachment, and the influential role of life experiences; 2) re-interpret select neurobiological research findings in FND cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and 3) discuss therapeutic implications. While we continue to support that FND is mechanistically and etiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology, and cognitive-affective neuroscience.
Anxiety in a patient with physical complaints should prompt an evaluation for somatization.
The biopsychosocial formulation is foundational to case conceptualization in functional movement disorder and related functional neurological conditions. In this chapter, a practical approach to the development of a patient-centered biopsychosocial model in patients with functional movement disorder is put forth, highlighting roles for predisposing vulnerabilities, acute precipitants and perpetuating factors. The use of this approach underscores that “one size does not fit all” in contextualizing the development and maintenance of functional neurological symptoms in a given patient. Notably, a well-constructed biopsychosocial formulation is an important step in identifying potential treatment targets. Furthermore, the biopsychosocial formulation can be used to contextualize why a given patient may not be optimally responding to treatment.KeywordsFunctional movement disorderFunctional neurological disorderBiopsychosocialNeuropsychiatry
Background:
Functional neurological disorder (FND) is common, and symptoms can be severe. There have been no international large-scale studies of patient experiences of FND.
Methods:
We created a patient questionnaire to assess FND patient characteristics, symptom comorbidities, and illness perceptions. Respondents were recruited internationally through an open access questionnaire via social media and patient groups over a month-long period.
Results:
In total, 1048 respondents from sixteen countries participated. Mean age was 42 years (86% female). Median FND symptom duration was five years, and median time from first symptom to diagnosis was two years. Mean number of current symptoms (core FND and associated) was 9.9. Many respondents had associated symptoms, for example fatigue (93%), memory difficulties (80%), and headache (70%). Self-reported psychiatric comorbidities were relatively common (depression (43%), anxiety (51%), panic (20%), and post-traumatic stress disorder (22%)). Most respondents reported that FND had multiple causes, including physical and psychological.
Conclusions:
This large survey adds further evidence that people with FND typically have high levels of multiple symptom comorbidity with resultant distress. It also supports the notion that associated physical symptoms are of particular clinical significance in FND patients. Dualistic ideas of FND were not supported by respondents, who generally preferred to conceptualise the disorder as one at the interface of mind and brain. We highlight the need for a broad approach to this poorly served patient group. Potential selection and response biases due to distribution of the survey online, mostly via FND patient groups, is a key limitation.
Cognitive symptoms are common, and yet many who seek help for cognitive symptoms neither have, nor go on to develop, dementia. A proportion of these people are likely to have functional cognitive disorders, a subtype of functional neurological disorders, in which cognitive symptoms are present, associated with distress or disability, but caused by functional alterations rather than degenerative brain disease or another structural lesion. In this Review, we have systematically examined the prevalence and clinical associations of functional cognitive disorders, and related phenotypes, within the wider cognitive disorder literature. Around a quarter of patients presenting to memory clinics received diagnoses that might indicate the presence of functional cognitive disorders, which were associated with affective symptoms, negative self-evaluation, negative illness perceptions, non-progressive symptom trajectories, and linguistic and behavioural differences during clinical interactions. Those with functional cognitive disorder phenotypes are at risk of iatrogenic harm because of misdiagnosis or inaccurate prediction of future decline. Further research is imperative to improve diagnosis and identify effective treatments for functional cognitive disorders, and better understanding these phenotypes will also improve the specificity of diagnoses of prodromal degenerative brain disease.