1
|
Cabreira V, Alty J, Antic S, Araújo R, Aybek S, Ball HA, Baslet G, Bhome R, Coebergh J, Dubois B, Edwards M, Filipović SR, Frederiksen KS, Harbo T, Hayhow B, Howard R, Huntley J, Isaacs J, LaFrance WC, Larner AJ, Di Lorenzo F, Main J, Mallam E, Marra C, Massano J, McGrath ER, McWhirter L, Moreira IP, Nobili F, Pennington C, Tábuas-Pereira M, Perez DL, Popkirov S, Rayment D, Rossor M, Russo M, Santana I, Schott J, Scott EP, Taipa R, Tinazzi M, Tomic S, Toniolo S, Tørring CW, Wilkinson T, Frostholm L, Stone J, Carson A. Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study. Eur J Neurol 2024:e16318. [PMID: 38700361 DOI: 10.1111/ene.16318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/18/2024] [Accepted: 04/11/2024] [Indexed: 05/05/2024]
Abstract
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.
Collapse
Affiliation(s)
- Verónica Cabreira
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jane Alty
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia
| | - Sonja Antic
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Rui Araújo
- Department of Neurology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Porto, Portugal
| | - Selma Aybek
- Neurology, Faculty of Sciences and Medicine, Fribourg University, Fribourg, Switzerland
| | - Harriet A Ball
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rohan Bhome
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
- Centre for Medical Image Computing, University College London, London, UK
| | - Jan Coebergh
- Department of Neurology, St George's University of London, London, UK
| | - Bruno Dubois
- Department of Neurology, Institut de la mémoire et de la maladie d'Alzheimer (IM2A), AP-HP, Brain Institute, Sorbonne University, Paris, France
| | - Mark Edwards
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry Psychology and Neurosciences, Kings College London, London, UK
| | - Saša R Filipović
- University of Belgrade Institute for Medical Research, Belgrade, Serbia
| | - Kristian Steen Frederiksen
- Clinical Trial Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bradleigh Hayhow
- Department of Neurology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Jeremy Isaacs
- Department of Neurology, St George's University of London, London, UK
| | - William Curt LaFrance
- Alpert Medical School, Brown University, Providence, Rhode Island, USA
- Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Andrew J Larner
- Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Francesco Di Lorenzo
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - James Main
- Bristol Dementia Wellbeing Service, Devon Partnership NHS Trust, Bristol, UK
| | | | - Camillo Marra
- Department of Neuroscience, Catholic University of the Sacred Heart, Memory Clinic - Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - João Massano
- Department of Neurology, Centro Hospitalar Universitário São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine University of Porto, Porto, Portugal
| | - Emer R McGrath
- School of Medicine, University of Galway, Galway, Ireland
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Isabel Portela Moreira
- Neurology Department, Private Hospital of Gaia of the Trofa Saúde Group, Vila Nova de Gaia, Portugal
| | - Flavio Nobili
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Catherine Pennington
- Clinical Lecturer, University of Edinburgh, Edinburgh, UK
- Neurology Department, NHS Forth Valley, Larbert, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Miguel Tábuas-Pereira
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - David L Perez
- Department of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Dane Rayment
- Rosa Burden Centre for Neuropsychiatry, Southmead Hospital, Bristol, UK
| | - Martin Rossor
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Isabel Santana
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology, University of Coimbra, Coimbra, Portugal
| | - Jonathan Schott
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Emmi P Scott
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ricardo Taipa
- Neuropathology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Svetlana Tomic
- Department of Neurology, University Hospital Center Osijek, Medical School on University of Osijek, Osijek, Croatia
| | - Sofia Toniolo
- Cognitive Disorder Clinic, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Tim Wilkinson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Lisbeth Frostholm
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
2
|
Gasquoine PG. Self-reported anterograde memory loss in older persons that is not validated on neuropsychological assessment: Considerations for a dissociative diagnosis. APPLIED NEUROPSYCHOLOGY. ADULT 2024:1-6. [PMID: 38615907 DOI: 10.1080/23279095.2024.2341801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
The past decade has witnessed amplified public awareness of age-related dementias. This has resulted in a dramatic rise in the number of older persons referred to memory clinics with a primary complaint of self-reported memory loss without an antecedent neurological event (e.g., stroke) who produce neuropsychological test profiles that lack evidence of such impairment. Since the latter part of the 19th century, a confusing array of changing terminology, criteria, and perceived causation have been ascribed to patients with unverified medical symptoms to implicate psychological causation. Such terms are often misperceived by laypersons as reflecting character flaws or malingering. Of import for clinical neuropsychologists, the 11th edition of the International Classification of Diseases added cognitive to symptoms eligible for a diagnosis of the modern formulation, dissociative neurological symptom disorder. One dissociative option for referrals with self-reported neurocognitive symptoms not validated on neuropsychological testing is functional memory disorder, conceived as a psychological disorder where emotional distress is plausibly related to the perceived memory loss but is of less severity than would warrant a major depressive or anxiety diagnosis. If evidence of psychological distress or behavioral impairment is not present the referral likely reflects the increased public awareness of age-related dementias interacting with the high base rate of self-perceived memory loss in the general population. In such cases, a dissociative diagnosis should be avoided as there is evidence of neither a medical nor a psychological disorder. A summary statement of not dementia or similar is likely sufficient to help the patient.
Collapse
Affiliation(s)
- Philip Gerard Gasquoine
- Department of Psychological Science, University of Texas Rio Grande Valley, Edinburg, TX, USA
| |
Collapse
|
3
|
Silverberg ND, Rush BK. Neuropsychological evaluation of functional cognitive disorder: A narrative review. Clin Neuropsychol 2024; 38:302-325. [PMID: 37369579 DOI: 10.1080/13854046.2023.2228527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
Objective: To critically review contemporary theoretical models, diagnostic approaches, clinical features, and assessment findings in Functional Cognitive Disorder (FCD), and make recommendations for neuropsychological evaluation of this condition. Method: Narrative review. Results: FCD is common in neuropsychological practice. It is characterized by cognitive symptoms that are not better explained by another medical or psychiatric disorder. The cognitive symptoms are associated with distress and/or limitations in daily functioning, but are potentially reversible with appropriate identification and treatment. Historically, a variety of diagnostic frameworks have attempted to capture this condition. A contemporary conceptualization of FCD positions it as a subtype of Functional Neurological Disorder, with shared and unique etiological factors. Patients with FCD tend to perform normally on neuropsychological testing or demonstrate relatively weak memory acquisition (e.g. list learning trials) in comparison to strong attention and delayed recall performance. Careful history-taking and behavioral observations are essential to support the diagnosis of FCD. Areas of ongoing controversy include operationalizing "internal inconsistencies" and the role of performance validity testing. Evidence for targeted interventions remains scarce. Conclusions: Neuropsychologists familiar with FCD can uniquely contribute to the care of patients with this condition by improving diagnostic clarity, richening case formulation, communicating effectively with referrers, and leading clinical management. Further research is needed to refine diagnosis, prognosis, and treatment.
Collapse
Affiliation(s)
- Noah D Silverberg
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
- Rehabilitation Research Program, Centre for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver, British Columbia, Canada
| | - Beth K Rush
- Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
4
|
Cabreira V, McWhirter L, Carson A. Functional Cognitive Disorder: Diagnosis, Treatment, and Differentiation from Secondary Causes of Cognitive Difficulties. Neurol Clin 2023; 41:619-633. [PMID: 37775194 DOI: 10.1016/j.ncl.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Functional cognitive disorder is an increasingly common cause of referral to the memory clinic. As a substantial source of disability, clinicians involved in the management of patients with cognitive complaints need to familiarize themselves with this important differential diagnosis. Our approach focuses on the identification of positive features of internal inconsistency (historical and clinical clues alongside patterns of performance) instead of an exclusionary approach. Although effective treatments are desperately needed, promising therapies include metacognitive retraining and cognitive-behavioral therapy modalities. Future research should focus on a better understanding of disease trajectories and outcomes as well as the development of evidence-based interventions.
Collapse
Affiliation(s)
- Verónica Cabreira
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
5
|
Roivainen E, Peura M, Pätsi J. Cognitive profile in functional disorders. Cogn Neuropsychiatry 2023; 28:424-436. [PMID: 37889124 DOI: 10.1080/13546805.2023.2275336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Patients with functional disorders (FD) often experience cognitive problems such as forgetfulness and distractibility alongside physical symptoms that cannot be attributed to a known somatic disease. METHOD Test scores of cognitive tests and psychiatric rating scales of 100 outpatients diagnosed with a functional disorder were compared to a control group (n = 300) of patients with other diagnoses and to test norms for the general population. RESULTS Out of the 100 patients with functional disorders, 59 reported significant subjective cognitive symptoms. A moderate difference (d = 0.5-0.7) was found between the FD group mean and the population mean in processing speed tests, as well as in four psychiatric rating scales (depression, anxiety, phobias, somatisation) but there were no statistically significant differences in verbal and nonverbal reasoning or in logical memory. Somatisation and logical verbal memory scores were higher in the FD group compared to the control group. CONCLUSION The findings of the study suggest that a decline in processing speed is a central feature in the cognitive profile of patients with functional disorders.
Collapse
Affiliation(s)
- Eka Roivainen
- Department of Medical Rehabilitation, Oulu University Hospital, Oulu, Finland
| | - Maria Peura
- Department of Medical Rehabilitation, Oulu University Hospital, Oulu, Finland
| | - Jukka Pätsi
- Department of Medical Rehabilitation, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
6
|
Cabreira V, Frostholm L, McWhirter L, Stone J, Carson A. Clinical signs in functional cognitive disorders: A systematic review and diagnostic meta-analysis. J Psychosom Res 2023; 173:111447. [PMID: 37567095 DOI: 10.1016/j.jpsychores.2023.111447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE Functional cognitive disorder (FCD) accounts for around a third of patients attending specialized memory clinics. It is also overrepresented in patients with other functional and somatic diagnoses. So far, no long-term diagnostic validity studies were conducted, and a positive diagnostic profile is yet to be identified. We aimed to review the literature on diagnostic signs and symptoms that allow for a discrimination between FCD and neurodegeneration. METHODS Systematic review of Ovid-Medline®, Embase and PsycINFO databases. Relevant clinical features were extracted including demographics, symptom history, comorbidities, language and interaction profiles and cognitive assessments. Studies with quantifiable diagnostic accuracy data were included in a diagnostic meta-analysis. RESULTS Thirty studies (N = 8602) were included. FCD patients were younger, more educated, and more likely to have a family history of older onset dementia, abrupt symptom onset, and higher rates of anxiety, depression and sleep disturbance. Promising language profiles include longer duration of spoken answer, elaborated examples of memory failures, ability to answer compound and personal questions, and demonstration of working memory during interaction. The pooled analysis of clinical accuracy of different signs revealed that attending alone and bringing a handwritten list of problems particularly increase the odds of a FCD diagnosis. Current evidence from neuropsychometric studies in FCD is scarce. CONCLUSIONS Our systematic review reinforces that positive signs contribute for an early differentiation between FCD and neurodegeneration in patients presenting with memory complaints. It is the first to attain quantitative value to clinical observations. These results will inform future diagnostic decision tools and intervention testing.
Collapse
Affiliation(s)
- Verónica Cabreira
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.
| | - Lisbeth Frostholm
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
7
|
Wright LM, De Marco M, Venneri A. Current Understanding of Verbal Fluency in Alzheimer's Disease: Evidence to Date. Psychol Res Behav Manag 2023; 16:1691-1705. [PMID: 37179686 PMCID: PMC10167999 DOI: 10.2147/prbm.s284645] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/05/2023] [Indexed: 05/15/2023] Open
Abstract
Since their development, verbal fluency tests (VFTs) have been used extensively throughout research and in clinical settings to assess a variety of cognitive functions in diverse populations. In Alzheimer's disease (AD), these tasks have proven particularly valuable in identifying the earliest forms of cognitive decline in semantic processing and have been shown to relate specifically to brain regions associated with the initial stages of pathological change. In recent years, researchers have developed more nuanced techniques to evaluate verbal fluency performance, extracting a wide range of cognitive metrics from these simple neuropsychological tests. Such novel techniques allow for a more detailed exploration of the cognitive processes underlying successful task performance beyond the raw test score. The versatility of VFTs and the richness of data they may provide, in light of their low cost and speed of administration, therefore, highlight their potential value both in future research as outcome measures for clinical trials and in a clinical setting as a screening measure for early detection of neurodegenerative diseases.
Collapse
Affiliation(s)
- Laura M Wright
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Matteo De Marco
- Department of Life Sciences, Brunel University London, London, UK
| | - Annalena Venneri
- Department of Life Sciences, Brunel University London, London, UK
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| |
Collapse
|
8
|
Abstract
BACKGROUND Functional cognitive disorders (FCD) are an important differential diagnosis of neurodegenerative disease. The utility of suggested diagnostic features has not been prospectively explored in "real world" clinical populations. This study aimed to identify positive clinical markers of FCD. METHODS Adults with cognitive complaints but not dementia were recruited from memory, neurology, and neuropsychiatry clinics. Participants underwent structured interview, Mini International Neuropsychiatric Interview, Montreal Cognitive Assessment, Luria 3-step, interlocking fingers, digit span and Medical Symptom Validity Test, Patient Health Questionnaire 15, Hospital Anxiety and Depression Scale, Multifactorial Memory Questionnaire, and Pittsburgh Sleep Quality Inventory. Potential diagnostic variables were tested against expert consensus diagnosis using logistic regression. RESULTS FCD were identified in 31/49 participants. Participants with FCD were younger, spoke for longer when prompted "Tell me about the problems you've been having," and had more anxiety and depression symptoms and psychiatric diagnoses than those without FCD. There were no significant differences in sex, education, or cognitive scores. Younger age and longer spoken response predicted FCD diagnosis in a model which explained 74% of diagnostic variability and had an area under the curve (AUC) of 94%. CONCLUSIONS A detailed description of cognitive failure is a sensitive and specific positive feature of FCD, demonstrating internal inconsistency between experienced and observed function. Cognitive and performance validity tests appear less helpful in FCD diagnosis. People with FCD are not "worried well" but often perform poorly on tests, and have more anxiety, depression, and physical symptoms than people with other cognitive disorders. Identifying diagnostic profiles is an important step toward parity of esteem for FCDs, as differential diagnoses of neurodegenerative disease and an independent target for clinical trials.
Collapse
|
9
|
Borelli WV, de Senna PN, Brum WS, Schumacher-Schuh AF, Zimmer ER, Fagundes Chaves ML, Castilhos RM. Functional Cognitive Disorder Presents High Frequency and Distinct Clinical Profile in Patients With Low Education. Front Aging Neurosci 2022; 14:789190. [PMID: 35431909 PMCID: PMC9011344 DOI: 10.3389/fnagi.2022.789190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/04/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Functional Cognitive Disorder (FCD) is a non-degenerative, common cause of memory complaint in patients with high educational levels. FCD has been insufficiently described in individuals with low education. Here, we investigated the frequency of FCD among individuals with low education. Methods We analyzed retrospectively all new referrals from primary care to a tertiary memory clinic from 2014 to 2021. Final diagnosis, diagnostic work-up, clinical and cognitive testing data were compared between FCD and other diagnoses, grouped as Neurodegenerative Disorders (NDD). A regression model was used to assess the effect of education on the diagnosis. Data is shown in Mean [SD]. Results A total of 516 individuals (70.76 [10.3] years) with low educational attainment (4.5 [3.94] years) were divided into FCD (146, 28.3%) and NDD. Compared with NDD, FCD patients showed lower age at presentation (66.2 [9.4] vs. 72.6 [10.2], p < 0.001), higher Mini-Mental State Examination (MMSE) scores (22.4 [6.2] vs. 14.7 [7.8], p < 0.001) and Geriatric Depression Scale (GDS) scores (7.4 [5.4] vs. 5.3 [3.7], p = 0.0001). Discussion Surprisingly, FCD was the most frequent diagnosis in a low educational setting. However, education was not associated with FCD. Individuals presenting FCD showed a distinct clinical profile, including younger age and higher depressive scores. Strategies to identify FCD in primary care settings may benefit both patients and healthcare systems.
Collapse
Affiliation(s)
- Wyllians Vendramini Borelli
- Cognitive and Behavioral Neurology Center, Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Biological Sciences: Pharmacology and Therapeutics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- *Correspondence: Wyllians Vendramini Borelli,
| | - Priscylla Nunes de Senna
- Cognitive and Behavioral Neurology Center, Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Wagner Scheeren Brum
- Graduate Program in Biological Sciences: Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Artur Francisco Schumacher-Schuh
- Cognitive and Behavioral Neurology Center, Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Departamento de Farmacologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Eduardo R. Zimmer
- Graduate Program in Biological Sciences: Pharmacology and Therapeutics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Graduate Program in Biological Sciences: Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Departamento de Farmacologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Márcia Lorena Fagundes Chaves
- Cognitive and Behavioral Neurology Center, Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Raphael Machado Castilhos
- Cognitive and Behavioral Neurology Center, Serviço de Neurologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| |
Collapse
|
10
|
Chutko L, Surushkina S. Functional cognitive disorders. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:43-48. [DOI: 10.17116/jnevro202212202143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
11
|
OUP accepted manuscript. Arch Clin Neuropsychol 2022; 37:1158-1176. [DOI: 10.1093/arclin/acac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/14/2022] Open
|
12
|
De Marco M, Blackburn DJ, Venneri A. Serial Recall Order and Semantic Features of Category Fluency Words to Study Semantic Memory in Normal Ageing. Front Aging Neurosci 2021; 13:678588. [PMID: 34413764 PMCID: PMC8370562 DOI: 10.3389/fnagi.2021.678588] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Category Fluency Test (CFT) is a common measure of semantic memory (SM). Test performance, however, is also influenced by other cognitive functions. We here propose a scoring procedure that quantifies the correlation between the serial recall order (SRO) of words retrieved during the CFT and a number of linguistic features, to obtain purer SM measures. To put this methodology to the test, we addressed a proof-of-concept hypothesis whereby, in alignment with the literature, older adults would show better SM. Methods: Ninety participants (45 aged 18-21 years; 45 aged 70-81 years) with normal neurological and cognitive functioning completed a 1-min CFT. SRO was scored as an ordinal variable incrementing by one unit for each valid entry. Each word was also scored for 16 additional linguistic features. Participant-specific normalised correlation coefficients were calculated between SRO and each feature and were analysed with group comparisons and graph theory. Results: Younger adults showed more negative correlations between SRO and "valence" (a feature of words pleasantness). This was driven by the first five words generated. When analysed with graph theory, SRO had significantly higher degree and lower betweenness centrality among older adults. Conclusion: In older adults, SM relies significantly less on pleasantness of entries typically retrieved without semantic control. Moreover, graph-theory metrics indicated better optimised links between SRO and linguistic features in this group. These findings are aligned with the principle whereby SM processes tend to solidify with ageing. Although additional work is needed in support of an SRO-based item-level scoring procedure of CFT performance, these initial findings suggest that this methodology could be of help in characterising SM in a purer form.
Collapse
Affiliation(s)
- Matteo De Marco
- Department of Life Sciences, Brunel University London, London, United Kingdom.,Department of Neuroscience, The University of Sheffield, Sheffield, United Kingdom
| | - Daniel J Blackburn
- Department of Neuroscience, The University of Sheffield, Sheffield, United Kingdom
| | - Annalena Venneri
- Department of Life Sciences, Brunel University London, London, United Kingdom.,Department of Neuroscience, The University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
13
|
Functional Cognitive Disorders (FCD): How Is Metacognition Involved? Brain Sci 2021; 11:brainsci11081082. [PMID: 34439701 PMCID: PMC8393342 DOI: 10.3390/brainsci11081082] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022] Open
Abstract
Functional cognitive disorders (FCD) have become a subject of increasing clinical interest in recent years, in part because of their high prevalence amongst patients attending dedicated memory clinics. Empirical understanding of FCD based on observational studies is growing, suggesting a relationship to other functional neurological disorders (FND) based on shared phenomenology. However, understanding of FCD at the theoretical level has been lacking. One suggestion has been that FCD are disorders of metacognition, most usually of metamemory. In this article, a brief overview of these constructs is presented along with existing evidence for their impairment in FCD. Previous adaptations of theoretical models of FND to accommodate FCD are reviewed. A novel application to FCD of Nelson and Narens’ monitoring and control model of metamemory is then attempted, positing an improper setting of the monitoring function, with examples of ecological relevance. Formulation of FCD in light of a metacognitive model of anosognosia is also considered. Although lacking mechanistic and neuroanatomical sophistication, this metacognitive formulation of FCD may give pointers for future hypothesis-driven research and a pragmatic basis for management strategies.
Collapse
|
14
|
Wright LM, De Marco M, Venneri A. A Graph Theory Approach to Clarifying Aging and Disease Related Changes in Cognitive Networks. Front Aging Neurosci 2021; 13:676618. [PMID: 34322008 PMCID: PMC8311855 DOI: 10.3389/fnagi.2021.676618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/04/2021] [Indexed: 01/12/2023] Open
Abstract
In accordance with the physiological networks that underlie it, human cognition is characterized by both the segregation and interdependence of a number of cognitive domains. Cognition itself, therefore, can be conceptualized as a network of functions. A network approach to cognition has previously revealed topological differences in cognitive profiles between healthy and disease populations. The present study, therefore, used graph theory to determine variation in cognitive profiles across healthy aging and cognitive impairment. A comprehensive neuropsychological test battery was administered to 415 participants. This included three groups of healthy adults aged 18-39 (n = 75), 40-64 (n = 75), and 65 and over (n = 70) and three patient groups with either amnestic (n = 75) or non-amnestic (n = 60) mild cognitive impairment or Alzheimer's type dementia (n = 60). For each group, cognitive networks were created reflective of test-to-test covariance, in which nodes represented cognitive tests and edges reflected statistical inter-nodal significance (p < 0.05). Network metrics were derived using the Brain Connectivity Toolbox. Network-wide clustering, local efficiency and global efficiency of nodes showed linear differences across the stages of aging, being significantly higher among older adults when compared with younger groups. Among patients, these metrics were significantly higher again when compared with healthy older controls. Conversely, average betweenness centralities were highest in middle-aged participants and lower among older adults and patients. In particular, compared with controls, patients demonstrated a distinct lack of centrality in the domains of semantic processing and abstract reasoning. Network composition in the amnestic mild cognitive impairment group was similar to the network of Alzheimer's dementia patients. Using graph theoretical methods, this study demonstrates that the composition of cognitive networks may be measurably altered by the aging process and differentially impacted by pathological cognitive impairment. Network alterations characteristic of Alzheimer's disease in particular may occur early and be distinct from alterations associated with differing types of cognitive impairment. A shift in centrality between domains may be particularly relevant in identifying cognitive profiles indicative of underlying disease. Such techniques may contribute to the future development of more sophisticated diagnostic tools for neurodegenerative disease.
Collapse
Affiliation(s)
- Laura M Wright
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Matteo De Marco
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Annalena Venneri
- Department of Neuroscience, University of Sheffield, Sheffield, United Kingdom.,Department of Life Sciences, Brunel University London, London, United Kingdom
| |
Collapse
|
15
|
Ball HA, McWhirter L, Ballard C, Bhome R, Blackburn DJ, Edwards MJ, Fleming SM, Fox NC, Howard R, Huntley J, Isaacs JD, Larner AJ, Nicholson TR, Pennington CM, Poole N, Price G, Price JP, Reuber M, Ritchie C, Rossor MN, Schott JM, Teodoro T, Venneri A, Stone J, Carson AJ. Functional cognitive disorder: dementia's blind spot. Brain 2020; 143:2895-2903. [PMID: 32791521 PMCID: PMC7586080 DOI: 10.1093/brain/awaa224] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/06/2020] [Accepted: 05/21/2020] [Indexed: 12/25/2022] Open
Abstract
An increasing proportion of cognitive difficulties are recognized to have a functional cause, the chief clinical indicator of which is internal inconsistency. When these symptoms are impairing or distressing, and not better explained by other disorders, this can be conceptualized as a cognitive variant of functional neurological disorder, termed functional cognitive disorder (FCD). FCD is likely very common in clinical practice but may be under-diagnosed. Clinicians in many settings make liberal use of the descriptive term mild cognitive impairment (MCI) for those with cognitive difficulties not impairing enough to qualify as dementia. However, MCI is an aetiology-neutral description, which therefore includes patients with a wide range of underlying causes. Consequently, a proportion of MCI cases are due to non-neurodegenerative processes, including FCD. Indeed, significant numbers of patients diagnosed with MCI do not 'convert' to dementia. The lack of diagnostic specificity for MCI 'non-progressors' is a weakness inherent in framing MCI primarily within a deterministic neurodegenerative pathway. It is recognized that depression, anxiety and behavioural changes can represent a prodrome to neurodegeneration; empirical data are required to explore whether the same might hold for subsets of individuals with FCD. Clinicians and researchers can improve study efficacy and patient outcomes by viewing MCI as a descriptive term with a wide differential diagnosis, including potentially reversible components such as FCD. We present a preliminary definition of functional neurological disorder-cognitive subtype, explain its position in relation to other cognitive diagnoses and emerging biomarkers, highlight clinical features that can lead to positive diagnosis (as opposed to a diagnosis of exclusion), and red flags that should prompt consideration of alternative diagnoses. In the research setting, positive identifiers of FCD will enhance our recognition of individuals who are not in a neurodegenerative prodrome, while greater use of this diagnosis in clinical practice will facilitate personalized interventions.
Collapse
Affiliation(s)
- Harriet A Ball
- Population Health Sciences, University of Bristol, BS8 1QU, UK
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Clive Ballard
- College of Medicine and Health, University of Exeter, EX1 2LU, UK
| | - Rohan Bhome
- Division of Psychiatry, University College London, W1T 7NF, UK
| | - Daniel J Blackburn
- Department of Neuroscience, Medical School, The University of Sheffield, S10 2TN, UK
| | - Mark J Edwards
- Neuroscience Research Centre, St George's, University of London, SW17 0RE, UK
| | - Stephen M Fleming
- Wellcome Centre for Human Neuroimaging, University College London, WC1N 3AR, UK
| | - Nick C Fox
- Dementia Research Centre, Department of Neurodegenerative Diseases, UCL Queen Square Institute of Neurology, WC1E 6BT, UK
| | - Robert Howard
- Division of Psychiatry, University College London, W1T 7NF, UK
| | | | - Jeremy D Isaacs
- Neuroscience Research Centre, St George's, University of London, SW17 0RE, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Andrew J Larner
- Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, L9 7LJ, UK
| | - Timothy R Nicholson
- Institute of Psychiatry Psychology and Neuroscience, King's College London, SE5 8AF, UK
| | | | - Norman Poole
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK
| | - Gary Price
- University College London Hospitals NHS Foundation Trust, NW1 2BU, UK
| | - Jason P Price
- Department of Neuropsychology, South Tees Hospitals NHS Foundation Trust, TS4 3BW, UK
| | - Markus Reuber
- Department of Neuroscience, Medical School, The University of Sheffield, S10 2TN, UK
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Martin N Rossor
- Dementia Research Centre, Department of Neurodegenerative Diseases, UCL Queen Square Institute of Neurology, WC1E 6BT, UK
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Diseases, UCL Queen Square Institute of Neurology, WC1E 6BT, UK
| | - Tiago Teodoro
- Neuroscience Research Centre, St George's, University of London, SW17 0RE, UK.,Instituto de Medicina Molecular, Universidade de Lisbon, 1649-028 Lisboa, Portugal
| | - Annalena Venneri
- Department of Neuroscience, Medical School, The University of Sheffield, S10 2TN, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| |
Collapse
|
16
|
Prediction of Cognitive Decline in Temporal Lobe Epilepsy and Mild Cognitive Impairment by EEG, MRI, and Neuropsychology. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2020; 2020:8915961. [PMID: 32549888 PMCID: PMC7256687 DOI: 10.1155/2020/8915961] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/06/2020] [Indexed: 12/20/2022]
Abstract
Cognitive decline is a severe concern of patients with mild cognitive impairment. Also, in patients with temporal lobe epilepsy, memory problems are a frequently encountered problem with potential progression. On the background of a unifying hypothesis for cognitive decline, we merged knowledge from dementia and epilepsy research in order to identify biomarkers with a high predictive value for cognitive decline across and beyond these groups that can be fed into intelligent systems. We prospectively assessed patients with temporal lobe epilepsy (N = 9), mild cognitive impairment (N = 19), and subjective cognitive complaints (N = 4) and healthy controls (N = 18). All had structural cerebral MRI, EEG at rest and during declarative verbal memory performance, and a neuropsychological assessment which was repeated after 18 months. Cognitive decline was defined as significant change on neuropsychological subscales. We extracted volumetric and shape features from MRI and brain network measures from EEG and fed these features alongside a baseline testing in neuropsychology into a machine learning framework with feature subset selection and 5-fold cross validation. Out of 50 patients, 27 had a decline over time in executive functions, 23 in visual-verbal memory, 23 in divided attention, and 7 patients had an increase in depression scores. The best sensitivity/specificity for decline was 72%/82% for executive functions based on a feature combination from MRI volumetry and EEG partial coherence during recall of memories; 95%/74% for visual-verbal memory by combination of MRI-wavelet features and neuropsychology; 84%/76% for divided attention by combination of MRI-wavelet features and neuropsychology; and 81%/90% for increase of depression by combination of EEG partial directed coherence factor at rest and neuropsychology. Combining information from EEG, MRI, and neuropsychology in order to predict neuropsychological changes in a heterogeneous population could create a more general model of cognitive performance decline.
Collapse
|
17
|
Larner AJ. Functional cognitive disorders: update on diagnostic status. Neurodegener Dis Manag 2020; 10:67-72. [DOI: 10.2217/nmt-2019-0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Many patients referred to cognitive disorders clinics are not found to have evidence of any neurological disorder(s) to account for their symptoms. Many demonstrate incongruence between their subjective cognitive symptoms and preserved social and occupational functions. The term ‘functional cognitive disorders’ (FCD) has been used to denote this diagnostic category. This article aims to review the current state of knowledge regarding FCD. Studies of FCD are in their infancy, but available evidence suggests positive diagnosis may be made based on typical clinical profiles, including language discourse and simple clinical signs. Concurrent mood disorder and sleep disturbance are common, as well as other functional disorders. Pathogenesis is yet to be determined, but a disorder of metamemory has been suggested.
Collapse
Affiliation(s)
- AJ Larner
- Cognitive Function Clinic, Walton Centre for Neurology & Neurosurgery, Liverpool, UK
| |
Collapse
|
18
|
McWhirter L, Ritchie C, Stone J, Carson A. Functional cognitive disorders: a systematic review. Lancet Psychiatry 2020; 7:191-207. [PMID: 31732482 DOI: 10.1016/s2215-0366(19)30405-5] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
19
|
Bhome R, McWilliams A, Huntley JD, Fleming SM, Howard RJ. Metacognition in functional cognitive disorder- a potential mechanism and treatment target. Cogn Neuropsychiatry 2019; 24:311-321. [PMID: 31389291 DOI: 10.1080/13546805.2019.1651708] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Functional Cognitive Disorder (FCD) is common. Despite this, there is no evidence-based consensus on how to treat FCD. Poor metacognitive ability has been suggested as a key mechanism underlying the disorder. This paper evaluates the proposal that strategies which improve metacognition could provide a mechanistically plausible translational therapy. Methods: We reviewed the existing literature relating to metacognition in FCD, previous strategies to improve metacognitive ability in FCD and whether metacognitive performance can be modulated. Results: Though limited, there is evidence to suggest that metacognition is impaired in FCD. Converging evidence from neuroimaging studies suggests that metacognitive performance can be modulated. The effectiveness of existing strategies to improve metacognition including cognitive training, psychoeducation and lifestyle interventions have been equivocal. Recently, a potential treatment option has emerged in the form of a computer-based metacognitive training paradigm. Conclusions: There is an urgent need for effective treatments in FCD. Impaired metacognition may be a plausible therapeutic target but, in the first instance, further research is required to demonstrate deficits in "local" metacognitive ability in FCD patients when measured objectively. If so, clinical trials of interventions, such as computerised metacognitive training, are required to evaluate their effectiveness in improving FCD symptoms.
Collapse
Affiliation(s)
- Rohan Bhome
- Division of Psychiatry, University College London , London , UK
| | - Andrew McWilliams
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London , London , UK.,Wellcome Centre for Human Neuroimaging, University College London , London , UK.,UCL Institute of Child Health , London , UK
| | | | - Stephen M Fleming
- Wellcome Centre for Human Neuroimaging, University College London , London , UK.,Max Planck University College London Centre for Computational Psychiatry and Ageing Research , London , UK
| | - Robert J Howard
- Division of Psychiatry, University College London , London , UK
| |
Collapse
|
20
|
Poole NA, Cope SR, Bailey C, Isaacs JD. Functional cognitive disorders: identification and management. BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.38] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
SUMMARYWe review the various functional cognitive disorders (FCDs) – complaints about memory function or another cognitive process in the absence of relevant neuropathology. These are increasingly coming to the attention of psychiatrists and neurologists and FCD encompasses some newly recognised conditions in addition to classic types such as pseudodementia and psychogenic amnesia. The clinical features, neuropsychological findings and treatment are presented and discussed.LEARNING OBJECTIVESAfter reading this article you will be able to:
•describe clinical features of FCD and how it differs from neurodegenerative causes of cognitive impairment•be able to subclassify cases of FCD using the proposed nosology•understand how to discuss the diagnosis with the patient and explain how the symptoms arise.
Collapse
|
21
|
Alexander M, Blackburn D, Reuber M. Patients' accounts of memory lapses in interactions between neurologists and patients with functional memory disorders. SOCIOLOGY OF HEALTH & ILLNESS 2019; 41:249-265. [PMID: 30171614 DOI: 10.1111/1467-9566.12819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
One of the most commonly made diagnoses in secondary care memory services is functional memory disorder (FMD). FMD is non-progressive and characterised by persistent worries about memory failures without objective evidence of cognitive impairment. This study explores how patients with FMD present their memory concerns. Utilizing video recordings of consultations between patients and neurologists in a memory clinic, we show that FMD patients account for their memory deficits as significant disruptions to their daily lives. Resonating with research which identified a dissonance between self-reports of memory functioning by FMD patients and the outcome of neuropsychological assessments, we demonstrate that, in giving a detailed account of their perceived memory problems, patients provide objective conversational evidence of their cognitive and memory capacity, implicitly undermining the claim of an objective problem. Using conversation analysis, we examine three of the more prominent interactional practices FMD patients draw on when attempting to communicate memory deficits to the doctor - they are (i) contrasts with a standard of 'normal'; (ii) third-party observations; and (iii) direct reported speech. These interactional features are recurrent devices for displaying memory concerns as legitimate problems, embedded within patients' accounts of their day-to-day lives.
Collapse
Affiliation(s)
- Marc Alexander
- School of Social Sciences, Loughborough University, Loughborough, UK
| | - Daniel Blackburn
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| |
Collapse
|
22
|
Teodoro T, Edwards MJ, Isaacs JD. A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: systematic review. J Neurol Neurosurg Psychiatry 2018; 89:1308-1319. [PMID: 29735513 PMCID: PMC6288708 DOI: 10.1136/jnnp-2017-317823] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/24/2018] [Accepted: 04/10/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Functional cognitive disorder (FCD) describes cognitive dysfunction in the absence of an organic cause. It is increasingly prevalent in healthcare settings yet its key neuropsychological features have not been reported in large patient cohorts. We hypothesised that cognitive profiles in fibromyalgia (FM), chronic fatigue syndrome (CFS) and functional neurological disorders (FNDs) would provide a template for characterising FCD. METHODS We conducted a systematic review of studies with cognition-related outcomes in FM, CFS and FND. RESULTS We selected 52 studies on FM, 95 on CFS and 39 on FND. We found a general discordance between high rates of subjective cognitive symptoms, including forgetfulness, distractibility and word-finding difficulties, and inconsistent objective neuropsychological deficits. Objective deficits were reported, including poor selective and divided attention, slow information processing and vulnerability to distraction. In some studies, cognitive performance was inversely correlated with pain, exertion and fatigue. Performance validity testing demonstrated poor effort in only a minority of subjects, and patients with CFS showed a heightened perception of effort. DISCUSSION The cognitive profiles of FM, CFS and non-cognitive FND are similar to the proposed features of FCD, suggesting common mechanistic underpinnings. Similar findings have been reported in patients with mild traumatic brain injury and whiplash. We hypothesise that pain, fatigue and excessive interoceptive monitoring produce a decrease in externally directed attention. This increases susceptibility to distraction and slows information processing, interfering with cognitive function, in particular multitasking. Routine cognitive processes are experienced as unduly effortful. This may reflect a switch from an automatic to a less efficient controlled or explicit cognitive mode, a mechanism that has also been proposed for impaired motor control in FND. These experiences might then be overinterpreted due to memory perfectionism and heightened self-monitoring of cognitive performance.
Collapse
Affiliation(s)
- Tiago Teodoro
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK.,Instituto de Medicina Molecular Faculdade de Medicina, Universidade de Lisboa & Serviço de Neurologia Hospital de Santa Maria, Lisboa, Portugal
| | - Mark J Edwards
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jeremy D Isaacs
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|