The role of neuropsychology in the care of patients with functional neurological symptom disorder

Abstract

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.

Full text

Short Review
The role of neuropsychology in the care of patients with functional
neurological symptom disorder
Ryan Van Patten1
,
2, Kristen Mordecai3and W. Curt LaFrance Jr1
,
2
,
4
1Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA, 2Department of Psychiatry and Human Behavior,
Brown University, Providence, RI, USA, 3VA Maryland Health Care System, Baltimore, MD, USA and 4Rhode Island Hospital, Providence, RI, USA
Abstract
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.
Keywords: Functional neurological disorder; conversion disorder; neuropsychology; cognition; education; integrated care
(Received 9 January 2024; final revision 3 April 2024; accepted 6 May 2024)
Introduction to functional neurological symptom disorder
Functional neurological symptom disorder (FNSD) is a neuro-
psychiatric condition presenting with various neurological signs/
symptoms and associated with neural network dysfunction rather
than focal neuroanatomical lesions (Hallett et al., 2022). FNSD is
common globally (Kanemoto et al., 2017), on the order of ∼100
cases per 100,000 (Asadi-Pooya, 2021). It also has a large economic
(>$1.2 billion annually; Stephen et al., 2021) and public health
impact, comparable to that of well-known neurological conditions
such as epilepsy (Asadi-Pooya et al., 2021). For example, in
functional seizures, >50% of patients have neuropsychiatric/
medical comorbidities (Brown & Reuber, 2016a; Jennum et al.,
2019), a majority are unemployed and/or on disability (Salinsky
et al., 2018), and mortality is high (Asadi-Pooya, 2021).
FNSD can present with different symptom manifestations,
leading to the development of subordinate diagnostic groups that
coalesce around the clinical phenotypes. Three of the most
common FNSD subtypes with associated cognitive concerns are:
functional seizures (FS), functional cognitive disorder (FCD), and
functional motor disorder (FMD; Table 1). FS refers to time-
limited, paroxysmal motor, sensory, and cognitive alterations that
resemble epileptic seizures but lack epileptiform activity (LaFrance
et al., 2013); FCD is a cognitive disorder presenting with
impairments occurring within a cognitive domain and
inconsistently across situations (Ball et al., 2020); and FMD
reflects a family of movement abnormalities that are incongruent
with respect to classical neurophysiological mechanisms (Perez
et al., 2021).
A major recent advancement in the identification of FNSD has
been an improved understanding that FNSDs can be diagnosed via
positive signs, meaning that they are not simply the end result of
having ruled out all other possibilities via a plethora of negative
medical tests (Espay et al., 2018). Instead, there are sensitive and
specific behavioral and/or physiological features, focusing on
neuroanatomic inconsistency and incongruity, which allow for a
“rule-in”determination (Table 1). Critically, when made by
experienced clinicians, diagnoses of FNSD tend to be accurate and
stable across time (Stone et al., 2005,2009), with rates of
misdiagnosis being similarly low to those of other neurological
conditions (Gelauff et al., 2019; Walzl et al., 2019).
Cognitive deficits are a core diagnostic criterion in FCD but not
in FS/FMD. However, cognitive difficulties are common in all three
FNSD subtypes (∼80% of patients with FS/FMD; Butler et al.,
2021), and these problems limit treatment gains and reduce quality
of life (Jones et al., 2016;Věchetová et al., 2018). For example, some
evidence suggests that deficits in processing speed are common in
FNSDs (Van Patten et al., in press) and may be worse in some
FNSDs than in other somatic disorders (De Vroege et al., 2021).
Corresponding author: R. Van Patten; Email: ryan_van_patten@brown.edu
Cite this article: Van Patten R., Mordecai K., & LaFrance W.C., Jr. The role of neuropsychology in the care of patients with functional neurological symptom disorder. Journal of the
International Neuropsychological Society,1–8, https://doi.org/10.1017/S1355617724000249
© The Author(s), 2024. Published by Cambridge University Press on behalf of International Neuropsychological Society. This is an Open Access article, distributed under the terms of the
Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is
properly cited.
Journal of the International Neuropsychological Society (2024), 1–8
doi:10.1017/S1355617724000249
https://doi.org/10.1017/S1355617724000249 Published online by Cambridge University Press

More generally, impaired selective and divided attention has been
proposed as a transdiagnostic feature of all FNSDs, possibly driven
by excessive interoceptive monitoring, which attenuates the
“attentional reserve”available for pursuing external goals and
leads to a diffuse and nonspecific cognitive profile (Teodoro et al.,
2018; Willment et al., 2015).
Frameworks
Historical models of FNSD focused primarily or exclusively on
psychopathology (particularly trauma) as the etiological under-
pinning (Zepf, 2015). However, not all patients with FNSD have an
abuse history, and although mental health is still known to be a
critical factor, contemporary frameworks highlight the interplay of
etiological relationships, including between neurobiology, adverse
life events, emotional processing, and cognitive control (Brown &
Reuber, 2016b; Hallett et al., 2022). For example, abnormalities in
connectivity between limbic structures and motor control circuits
could be partially responsible for symptom expression in some
FNSDs (Baizabal-Carvallo et al., 2019; Maurer et al., 2018), while
dysfunctional fronto/parietal emotion processing may be related to
frequent psychopathology and cognitive symptoms (Pick et al.,
2019; Teodoro et al., 2018).
Supplementing advancements in neural associations, the
nosology of FNSD has also changed across time. For example,
there is some debate about the degree to which FNSD should be
primarily conceptualized as a unitary construct versus centering on
individual subtypes. On one hand, there is accumulating evidence
for shared pathophysiology and underlying cognitive deficits
across FS, FCD, and FMD (Hallett et al., 2022; Teodoro et al.,
2018), arguing for a so-called “lumping”approach. On the other
hand, there is mixed evidence with respect to individual
phenotypes, with some data suggesting transdiagnostic presenta-
tions (Finkelstein & Popkirov, 2023; Forejtová et al., 2023), and
other literature highlighting unique symptom expressions (Kola &
LaFaver, 2022; Matin et al., 2017), possibly supporting “splitting.”
Currently, many researchers strike a balance, with some attention
spent on overlapping characteristics of all FNSD (e.g., functional
connectivity abnormalities; Drane et al., 2021; Pick et al., 2019) and
additional complementary investigations highlighting nonshared
symptoms and treatment approaches (e.g., response to interven-
tions; Goldstein et al., 2020; Poole et al., 2023).
From a clinical standpoint, an important framework that
informs the biopsychosocial formulation (Mack & LaFrance, 2022)
is that of predisposing, precipitating, and perpetuating factors for
FNSD (LaFrance & Devinsky, 2002). Predisposing factors are
longstanding risk factors that increase a person’s overall vulner-
ability to FNSD, precipitating factors are acute/subacute events
that represent a “final straw”in the initial presentation of an FNSD,
and perpetuating factors are ongoing stressors or experiences that
serve as barriers to healing and recovery (Ertan et al., 2022). For
example, predisposing factors for FNSDs could include childhood
adversity or chronic illness, precipitating factors could be a closed
head injury or a reaction to a vaccine, and perpetuating factors may
be medical/social stigma or protracted litigation (Chen &
LaFrance, 2021; Fung et al., 2023). Within this model, clinicians
can identify variables that guide decisions related to neuropsycho-
logical assessment (e.g., interview questions, test selection), case
conceptualization (e.g., etiology, contributing factors), and treat-
ment (e.g., psychoeducation, treatment planning). In terms of case
conceptualization, neuropsychologists and other clinicians can use
this biopsychosocial information to generate hypothesized
explanations for patients’persistent cognitive symptoms based
on the fear avoidance model, which has been applied to FNSDs
(LaFrance & Bjonaes, 2018). The model helps explain perpetuating
factors for treatment-resistant cognitive symptoms with a focus on
negative expectations and catastrophizing in some patients (e.g.,
believing that a mild TBI will cause severe brain damage;
Wijenberg et al., 2020), which can lead to anxiety/worry, avoidance
of cognitively-taxing tasks (e.g., work/school), and a corresponding
reduction in functional independence. Ultimately, using the
biopsychosocial framework to identify and discuss an individu-
alized formulation with a patient and their family is the current
gold standard of care in FNSD, particularly in the setting of an
interdisciplinary team, where a neuropsychologist can lean upon
their relevant foundational skills (Table 2) to offer clinical insights
into case conceptualization and treatment planning (Gilmour
et al., 2020; Keatley & Molton, 2022; Silverberg & Rush, 2023).
Management and treatment
Iatrogenesis
FNSD is difficult to treat due to persistent/disabling symptoms
(Ducroizet et al., 2023; Durrant et al., 2011; Gelauff et al., 2014,
2019), as well as frequent neuromedical and psychiatric
comorbidities (Carle-Toulemonde et al., 2023; Jennum et al.,
2019). Although poor outcomes in patients with FNSD are
partially attributable to inherent symptom severity/heterogeneity,
clinicians have also erred (Burke, 2019), as there have been
significant problems arising from underrecognition and frequent
misunderstandings about FNSD (Keynejad et al., 2017;
Table 1. Positive clinical features of three common FNDs
FND Subtype Positive Clinical Signs
Functional Seizures (FS) Prolonged video EEG monitoring, where the history and ictal semiology are consistent with FS, and the paroxysmal event(s)
is/are captured, documenting contemporaneous ictal semiology and a lack of epileptiform activity (LaFrance et al., 2013;
Milán-Tomás et al., 2018). Note that the term FS does not include physiologic nonepileptic events (e.g., cardiogenic,
autonomic).
Functional Cognitive
Disorder (FCD)
Clinical identification of internal inconsistency, where a patient demonstrates impairment in a cognitive domain in some
situations but not others (also known as contrasting function/dysfunction; Ball et al., 2020; Cabreira et al., 2023; McWhirter
et al., 2020a). Note that for diagnostic criteria to be met, the internal inconsistency itself must occur within a single
cognitive domain (e.g., intact memory scores with reported dense amnesia in everyday life), but patients with FCD can also
have concurrent cognitive dysfunction in other domains (e.g., executive dysfunction).
Functional Motor Disorder
(FMD)
A neurological exam/movement disorders evaluation in which motor evidence of inconsistency/incongruity is demonstrated,
such as Hoover’s sign or tremor entrainment. In Hoover’s sign, one leg shows reduced strength when examined directly,
but normal strength when attention is directed to the contralateral leg via a hip flexion movement (Aybek & Perez, 2022;
Daum et al., 2014; Perez et al., 2021).
2 Ryan Van Patten et al.
https://doi.org/10.1017/S1355617724000249 Published online by Cambridge University Press

Klinke et al., 2021; McWhirter et al., 2022). That is, confusion
stemming from “organic versus non-organic”distinctions (Stone
& Carson, 2017), dichotomizing mind/brain conceptualizations
(Rawlings & Reuber, 2018), and judgment/stigma about “medically
unexplained illnesses”(Foley et al., 2022), has led to a great deal of
avoidance and “passing the buck”occurring amongst clinicians
(Barnett et al., 2022; Ducroizet et al., 2023).
In one example of a common misconception, surveys of
neurologists and psychiatrists have documented beliefs that FNSD
is indistinguishable from factitious disorder or malingering (Dent
et al., 2020; Kanaan et al., 2011) in spite of a wealth of evidence to
the contrary (Edwards et al., 2023; McWhirter et al., 2020). This
literature shows that, when a patient with an FNSD has a
neurological symptom such as limb weakness or memory loss, the
symptom is not purposefully feigned in order to achieve secondary
gain and/or attention. Instead, there are impairments in
interoception and a sense of agency in people with FNSDs
(Drane et al., 2021; Pick et al., 2019), with a complex
pathophysiology that leads to a decrement in the volitional
control over sensorimotor experiences and that may contribute to
FNSD symptom expression (Hallett et al., 2022). Nevertheless, the
persistent idea that these patients are faking symptoms is
associated with skepticism, frustration, deprioritization, and even
discrimination amongst some clinicians, which can lead to
iatrogenesis (Foley et al., 2022; Rawlings & Reuber, 2018). This
risk for negative outcomes associated with misdiagnosis of FNSDs
as factitious disorder or malingering makes the judicious use and
careful interpretation of symptom and performance validity tests
by neuropsychologists a particularly important clinical function
(Table 2; Edwards et al., 2023; Silverberg & Rush, 2023).
Advancements in management and treatment
Multiple efforts have been made to improve outcomes for patients
with FNSDs, including (1) enhancements to medical education
(Barnett et al., 2022; Rawlings & Reuber, 2018), (2) guidelines for
communication with patients (Finkelstein et al., 2022; Rockliffe-
Fidler & Willis, 2019), (3) the development of evidence-based
psychotherapeutic interventions (Goldstein et al., 2020; LaFrance
et al., 2014), and (4) increased interdisciplinary care (Lidstone
et al., 2020; Petrie et al., 2023). Items 1 and 4 are expanded upon
below because of their relevance to neuropsychologists. Regarding
education, it has become well recognized that many clinicians lack
sufficient instruction in FNSD, leading to the knowledge gaps
mentioned above (Klinke et al., 2021; Rawlings & Reuber, 2018). In
response, several groups have constructed FNSD-specific teaching
initiatives. First, the Functional Neurological Disorder Society
(website) Education Committee has produced a wide variety of
interdisciplinary training resources, including content in the form
of freestanding webinars, podcast episodes, and an on-demand
virtual education course available for continuing education credits.
Second, Medina and colleagues (2021) piloted a series of six
60-minute workshops for psychiatry trainees and reported
improved knowledge of and comfort with FNSD, including
increased confidence in discussing diagnosis and treatment with
patients, as well as consensus beliefs that FNSD symptoms are
“real”(not faked or malingered). Third, providers from the U.S.
Veterans Administration created the Mind Brain Program
(website) to equip clinicians in managing neuropsychiatric
disorders. In this program, organization providers utilize online
educational platforms and 1-on-1 distance supervision for training
clinic programs, which is increasing nationwide access to evidence-
based therapy (LaFrance & Clark, 2024).
Efforts to promote interdisciplinary care seek to address the
multifaceted nature of FNSD within a biopsychosocial framework
that reduces stigma and individualizes the treatment approach
(Aybek & Perez, 2022;Gilmouretal.,2020). This movement can
be distinguished from a “siloed”model of care, where a patient
presents first to a neurologist and then is sent to an outside mental
health clinician, without either professional collaborating with
the other or assuming responsibility. In contrast, in an integrated
model, the patient initially undergoes a thorough neuropsychi-
atric assessment, which is then translated into a personalized
intervention provided by a collaborative team, addressing
physical/neurological (Nielsen et al., 2015), mental health
(Oriuwa et al., 2022), and social/situational (LaFaver et al.,
2021) concerns. To date, positive results have been found with
integrated interventions (Jacob et al., 2018; Jimenez et al., 2019;
Lidstone et al., 2020), although the role of neuropsychology has
been largely neglected, in spite of the prominence of cognitive
dysfunction across FNSD subtypes (Carle-Toulemonde et al.,
2023; Jones et al., 2016;Teodoroetal.,2018). That is,
neuropsychologists can contribute to an interdisciplinary
FNSD team with a thorough biopsychosocial clinical formu-
lation, cognitive assessment to characterize strengths and
weaknesses, and cognitive rehabilitation targeting the most
distressing and disabling symptoms.
Regarding options for cognitive rehabilitation, as yet there are
no formal evidence-based treatments specifically targeting FNSDs.
However, broad-based compensatory approaches have been
Table 2. Alignment of FNSD characteristics with neuropsychologists’knowledge and skills
Aspect of FNSDs Unique Foundational Skills of Neuropsychologists
Pathophysiology and symptoms that cut across traditional neurological (e.g.,
seizures, tremors) and traditional psychiatric (e.g., trauma, somatization)
arenas.
Integrated brain/behavior knowledge, including neurological syndromes,
cognitive functioning, and psychopathology.
Inconsistency in results from subjective and objective outcome measures,
possibly resulting in clinical confusion about symptom profiles.
Training in psychometrics and clinical assessment, including the
interpretation of discrepancies in results from self-report and cognitive
testing.
Confusion regarding differences between FNSDs and factitious disorder/
malingering
Knowledge of symptom and performance validity testing, allowing for a
well-informed assessment of noncredible performances and invalid data.
Heterogeneity and symptom complexity leading to the need for a
comprehensive biopsychosocial conceptualization to informed treatment
planning.
Strong background in integrating information from various assessment
methods, including review of history, clinical interviewing, symptom
inventories, and cognitive testing.
Frequent and undertreated cognitive symptoms. Ability to characterize and treat cognitive symptoms, via assessment and
neuropsychological rehabilitation.
Journal of the International Neuropsychological Society 3
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successfully used in other related disorders (e.g., psychosis, TBI,
stroke; Twamley et al., 2012,2015; Winkens et al., 2009) and are
available to clinicians. Until an FNSD-specific protocol is
published, neuropsychologists can adapt these general techniques
for use in patients with FNSDs in individual clinical scenarios.
For example, several case studies have successfully applied
compensatory techniques in FNSDs, including an example of
general cognitive rehabilitation combined with psychotherapy that
was associated with improvements on memory test scores (Laatsch
& Taber, 1997) and an application of techniques to address
processing speed, which improved mental slowness and other
cognitive symptoms (De Vroege et al., 2017).
Table 3. Recommendations for FNSD-specific education in neuropsychology training programs
Issue or Topic FNSD Subtype Learning Activity †Resource
Foundational Knowledge
FNSD and Subtypes †Watch Webinars from the Functional
Neurological Disorders Society
https://www.fndsociety.org/fnd-education
FNSD and Subtypes Listen to Podcasts from the Functional
Neurological Disorders Society
https://www.fndsociety.org/resources/podcasts
FNSD Broadly *Read Seminal Publications (Finkelstein et al., 2022; Hallett et al., 2022)
FNSD Broadly Watch a Webinar from Know
Neuropsychology
https://knowneuropsych.org/functional-neurological-
disorders/
FNSD Broadly Listen to a Podcast episode from
Navigating Neuropsychology
www.navneuro.com/108
FS *Read Seminal Publications and
Textbooks
(Brown & Reuber, 2016a; LaFrance Jr & Schachter,
2018)
FS Watch a Webinar from the International
League Against Epilepsy
https://www.ilae.org/education/ilae-curriculum
FS Listen to a Podcast episode from
Navigating Neuropsychology
www.navneuro.com/112
FS Watch a Webinar from the U.S.
Department of Veterans Affairs
https://www.youtube.com/watch?v=NlX-
yNTX86w&list=PL3AQ_JVoBEyzDfAHEptumOPB-
PFTH_ya-
FCD Listen to a Podcast episode from
Navigating Neuropsychology
www.navneuro.com/128
FCD *Read Seminal Publications (Ball et al., 2020; Silverberg & Rush, 2023)
FMD *Read Seminal Publications (Lidstone et al., 2020; Perez, et al., 2021)
Applied Knowledge
FNSD Broadly Complete a Digital Training from the
U.S. TRAIN site
TRAIN online site training in evidence-based therapy
https://www.train.org/main/welcome
FNSD and Subtypes Engage in a Clinical Case Presentation
with Supervisor and Peer Feedback
Local
FNSD and Subtypes Complete a Focused Literature Review
on a Clinically Oriented Topic in
FNSDs
Local
FS Read a Treatment Manual from the
Treatments that Work Series
Taking Control of Your Seizures: Workbook (Reiter
et al., 2015)
Treating Nonepileptic Seizures: Therapist Guide
(LaFrance Jr & Wincze, 2015)
FS Complete Digital Trainings from the
U.S. Department of Veterans Affairs
Talent Management System (TMS) trainings in
neurobehavioral therapy: Courses: 131003888,
131003872, 131004533 https://www.tms.va.gov/
Clinical Experience
FNSD and Subtypes Participate in Supervised
Neuropsychological Evaluations of
FNSD Patients
Local
FNSD and Subtypes Observe/Participate in an
Interdisciplinary Clinic
Local
Clinic Development
FNSD Broadly The VA Mind Brain Program https://marketplace.va.gov/innovations/va-mind-
brain-program
Networking
FNSD and Subtypes Join a Professional Society and Attend
a Conference from the Functional
Neurological Disorders Society
https://www.fndsociety.org/
Resources for Patients/Families
FNSD Broadly Browse a Website https://fndhope.org/
FNSD Broadly Browse a Website https://neurosymptoms.org/en/
FS Browse a Website https://nonepilepticseizures.com/
FS Browse a Website https://sites.google.com/sheffield.ac.uk/non-epileptic-
attacks/
*Two example publications are provided for FNSDs and for each of the three subtypes. These examples are not exhaustive and the reader may wish to select many additional papers from the
current bibliography in order to begin building a local repository of scientific work in FNSDs.
†Many resources provided are online/digital methods of education. There is growing interest in webinars and podcasts as formal didactic tools to assist in the achievement of competencies in
neuropsychology (Van Patten et al., 2022).
4 Ryan Van Patten et al.
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FNSD in neuropsychology
As the movement toward interdisciplinary FNSD care has gained
momentum (Lopez et al., 2023), a variety of allied healthcare
specialties have joined neurologists and psychiatrists as active
members of treatment teams. This is reflected in published
consensus statements in occupational therapy (Nicholson et al.,
2020), physical therapy (Nielsen et al., 2015), speech language
pathology (Baker et al., 2021), and general health service
psychology (Keatley & Molton, 2022). By contrast, the role of
neuropsychology is typically not detailed in discussions of
interdisciplinary FNSD care, in spite of the fact that neuro-
psychologists possess a relevant knowledge base and skillset that
would allow for unique insights in many clinical situations (see
Table 2).
In order to expand the role of neuropsychologists in the care of
patients with FNSD, it is first necessary to: (1) enhance FNSD-
specific education in neuropsychology training programs, and
(2) advocate for appropriate patient referrals and inclusion of
neuropsychologists in interdisciplinary teams. Regarding the
former, similar to physicians, many neuropsychologists do not
receive consistent/robust instruction on various FNSD presenta-
tions (including FCD; Silverberg & Rush, 2023), likely leading to
knowledge gaps and clinical uncertainty. Importantly, the field of
neuropsychology is ripe for the incorporation of more compre-
hensive content coverage of FNSDs due to significant ongoing
development and innovation in current training models. The
changes primarily revolve around the revision of the Houston
Conference Guidelines (Hannay et al., 1998), which is instantiated
in the Minnesota Update Conference (MNC). One overarching
goal of the MNC is to delineate entry level competencies for
practicing neuropsychology, linked to strategies for implementa-
tion within existing training programs. Similar to that of other
highly prevalent disorders with major public health impacts, FNSD
education should be integrated across neuropsychology training in
the form of coursework, didactics, clinical vignettes, discussions of
scientific literature, and other activities (Table 3). And as more
neuropsychologists become knowledgeable about and skilled in
FNSD-specific issues through educational efforts, it is incumbent
upon these professionals to advocate for a role in the care of
patients with FNSD (Table 4).
Conclusions
FNSD is prevalent and impactful but has been underrecognized in
all healthcare specialties, including neuropsychology. Recent years
have seen significant advancements in the FNSD literature that can
improve healthcare provision and outcomes for these patients.
Multiple specialties have proposed educational programs and
guidelines/recommendations for their profession’s role in
integrated treatment for FNSD patients. Neuropsychologists have
strong foundational brain-behavior skills that would allow for
positive contributions to FNSD patient care. To facilitate this
progress, the current review provides actionable recommendations
for incorporating FNSD education into neuropsychology training
and for further integrating neuropsychologists into current clinical
care models.
Funding statement. R. Van Patten receives funding from VA Providence, RR&D
Center for Neurorestoration and Neurotechnology. He engages in profit sharing
with the International Neuropsychological Society for Continuing Education
proceeds from the Navigating Neuropsychology podcast. He also receives royalties
from publication of the book, Becoming a Neuropsychologist: Advice and
Guidance for Students and Trainees (Springer, 2021). The research reported/
outlined here was supported by the Department of Veterans Affairs, Veterans
Health Administration, VISN 1 Career Development Award to Ryan Van Patten.
K. Mordecai has no financial disclosures.
W.C. LaFrance, Jr. receives editor’s royalties from the publication of Gates
and Rowan’s Nonepileptic Seizures, 3rd ed. (Cambridge University Press, 2010)
and 4th ed. (2018); author’s royalties for Taking Control of Your Seizures:
Workbook and Therapist Guide (Oxford University Press, 2015); has received
research support from the Department of Defense (DoD W81XWH-17-0169),
NIH (NINDS 5K23NS45902) [PI], VA Providence HCS, Center for
Neurorestoration and Neurorehabilitation, Rhode Island Hospital, the
American Epilepsy Society (AES), the Epilepsy Foundation, Brown
University and the Siravo Foundation; has served on the Epilepsy
Foundation New England Professional Advisory Board, the Functional
Neurological Disorder Society Board of Directors, the American
Neuropsychiatric Association Advisory Council; has received honoraria for
the American Academy of Neurology, AES and Behavioral Aspects of
Neurology Annual Meetings.
Competing interests. R. Van Patten has served on the editorial boards of
Archives of Clinical Neuropsychology, International Psychogeriatrics, Journal of
Clinical and Experimental Neuropsychology, Frontiers in Neurology, and
Frontiers in Psychology.
Table 4. Specific functions of neuropsychologists in the care of patients with functional neurological symptom disorder
Assessment and Diagnosis Oriented Interprofessional Oriented
•Clinical evaluations in patients with cognitive concerns (Alluri et al., 2020;
Willment et al., 2015). •Consultation with interdisciplinary teams about approaches to management
and treatment, given each patient’s unique cognitive profile and mental
health symptoms (LaFaver et al., 2021; M. R. Lopez & LaFrance, 2022).
•Delivery of FNSD diagnoses, either as a member of a care team or with
appropriate consultation with neurology (Aybek & Perez, 2022; Espay et al.,
2018).
Treatment Oriented Research and Teaching Oriented
•Communication with patients about individualized contributing factors and
appropriate treatment recommendations/referrals (Bennett et al., 2021;
Finkelstein et al., 2022).
•Contribution to research and scholarship in FNSD (Silverberg & Rush, 2023;
Van Patten et al., in press).
•Teaching, mentorship, and supervision of trainees centered on FNSD-specific
issues (Lehn et al., 2020; Medina et al., 2021; Milligan et al., 2022).•Development and implementation of individual or group-based cognitive
rehabilitation interventions (Laatsch & Taber, 1997).
•Education of the public about FNSD presentations and brain health (e.g., via
development of patient resources and provision of community-based
lectures).
•Implementation of evidence-based psychotherapeutic interventions focused
on FNSD symptoms and relevant contributing factors (LaFrance Jr et al., 2020;
Millstein et al., 2023).
Journal of the International Neuropsychological Society 5
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K. Mordecai has no competing interests.
W.C. LaFrance, Jr. has served on the editorial boards of Epilepsia, Epilepsy &
Behavior; Journal of Neurology, Neurosurgery and Psychiatry, and Journal of
Neuropsychiatry and Clinical Neurosciences; has served as a clinic development
consultant at University of Colorado Denver, Cleveland Clinic, Spectrum
Health, Emory University, Oregon Health Sciences University and Vanderbilt
University; and has provided medico legal expert testimony.
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https://doi.org/10.1017/S1355617724000249 Published online by Cambridge University Press