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BackgroundFunctional neurological disorder (FND) is characterised by neurological symptoms, such as seizures and abnormal movements. Despite its significance to patients, the clinical features of chronic pain in people with FND, and of FND in people with chronic pain, have not been comprehensively studied.MethodsWe systematically reviewed PubMed, Embase and PsycINFO for studies of chronic pain in adults with FND and FND in patients with chronic pain. We described the proportions of patients reporting pain, pain rating and timing, pain-related diagnoses and responsiveness to treatment. We performed random effects meta-analyses of the proportions of patients with FND who reported pain or were diagnosed with pain-related disorders.ResultsSeven hundred and fifteen articles were screened and 64 were included in the analysis. Eight case–control studies of 3476 patients described pain symptoms in a higher proportion of patients with FND than controls with other neurological disorders. A random effects model of 30 cohorts found that an estimated 55% (95% CI 46% to 64%) of 4272 patients with FND reported pain. Random effects models estimated diagnoses of complex regional pain syndrome in 22% (95% CI 6% to 39%) of patients, irritable bowel syndrome in 16% (95% CI 9% to 24%) and fibromyalgia in 10% (95% CI 8% to 13%). Five studies of FND diagnoses among 361 patients with chronic pain were identified. Most interventions for FND did not ameliorate pain, even when other symptoms improved.ConclusionsPain symptoms and pain-related diagnoses are common in FND. Classification systems and treatments should routinely consider pain as a comorbidity in patients with FND.

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.

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

BackgroundThe term ‘brain fog’ is increasingly used colloquially to describe difficulties in the cognitive realm. But what is brain fog? What sort of experiences do people talk about when they talk about brain fog? And, in turn, what might this tell us about potential underlying pathophysiological mechanisms? This study examined first-person descriptions in order to better understand the phenomenology of brain fog.MethodsPosts containing ‘brain fog’ were scraped from the social media platform Reddit, using python, over a week in October 2021. We examined descriptions of brain fog, themes of containing subreddits (topic-specific discussion forums), and causal attributions.Results1663 posts containing ‘brain fog’ were identified, 717 meeting inclusion criteria. 141 first person phenomenological descriptions depicted forgetfulness (51), difficulty concentrating (43), dissociative phenomena (34), cognitive ‘slowness’ and excessive effort (26), communication difficulties (22), ‘fuzziness’ or pressure (10) and fatigue (9). 50% (363/717) posts were in subreddits concerned with illness and disease: including COVID-19 (87), psychiatric, neurodevelopmental, autoimmune and functional disorders. 134 posts were in subreddits about drug use or discontinuation, and 44 in subreddits about abstention from masturbation. 570 posts included the poster’s causal attribution, the most frequent attribution being long COVID in 60/570 (10%).Conclusions‘Brain fog’ is used on Reddit to describe heterogeneous experiences, including of dissociation, fatigue, forgetfulness and excessive cognitive effort, and in association with a range of illnesses, drugs and behaviours. Encouraging detailed description of these experiences will help us better understand pathophysiological mechanisms underlying cognitive symptoms in health and disease.

AbstractBackgroundFunctional 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.MethodsAdults 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.ResultsFCD 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%.ConclusionsA 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.

AbstractObjectiveMany people present to health services with concern about cognitive symptoms. In a significant proportion those symptoms are not the result of pathologically defined brain disease. In some they are part of a functional cognitive disorder (FCD). We assessed the frequency of cognitive lapses in a non-clinical sample in order to consider the utility of frequency of cognitive lapses in diagnosing cognitive disorders.MethodsHealthy adults, who had never sought help for cognitive symptoms, completed a questionnaire, distributed via social media, about self-evaluation of cognitive function, frequency of cognitive lapses, and use of memory aids, including Schmitdke and Metternich’s functional memory disorder (FMD) inventory.ResultsOne hundred and twenty-four adults, aged 18–59 (median 23), most with further or higher education, responded. Thirty-one (25%) reported “fair” or “poor” memory. Forty-eight (39%) reported memory worse than 5 years ago, and 30 (24%) reported memory worse than others the same age. Participants endorsed a mean 13/18 specific cognitive lapses at least monthly. One hundred and eleven (89%) scored ≥4, the suggested cutoff for the FMD inventory.ConclusionsCognitive lapses described in FCDs are common in highly educated adults. The high frequency of lapses in this healthy population suggests self-reported frequency of lapses alone cannot discriminate FCDs from “normal” experiences. Further research is required to clarify the role of abnormal metacognition in FCD. Better understanding of the factors moderating subjective interpretation of cognitive failures will also aid development of better clinical risk-stratification methods in people concerned about future dementia.

Communication problems (eg, dysphonia, dysfluency and language and articulation disorders), swallowing disorders (dysphagia and globus), cough and upper airway symptoms, resulting from functional neurological disorder (FND), are commonly encountered by speech and language professionals. However, there are few descriptions in the literature of the most effective practical management approaches. This consensus document aims to provide recommendations for assessment and intervention that are relevant to both adults and young people. An international panel of speech and language professionals with expertise in FND were approached to take part. Participants responded individually by email to a set of key questions regarding best practice for assessment and interventions. Next, a video conference was held in which participants discussed and debated the answers to these key questions, aiming to achieve consensus on each issue. Drafts of the collated consensus recommendations were circulated until consensus was achieved. FND should be diagnosed on the basis of positive clinical features. Speech and language therapy for FND should address illness beliefs, self-directed attention and abnormal movement patterns through a process of education, symptomatic treatment and cognitive behavioural therapy within a supportive therapeutic environment. We provide specific examples of these strategies for different symptoms. Speech and language professionals have a key role in the management of people with communication and related symptoms of FND. It is intended that these expert recommendations serve as both a practical toolkit and a starting point for further research into evidence-based treatments.

AbstractBackground.Symptoms of functional neurological disorder have traditionally been thought to depend, in part, on patients’ ideas about symptoms rather than on the rules of pathophysiology. The possibility that functional cognitive symptoms might similarly reflect ideas of dementia has not been explored. We aimed to assess beliefs, through performance, about symptoms of dementia in healthy non-medical adults with the intention of identifying potential markers of functional cognitive disorders.Methods.Healthy volunteers were asked to simulate symptoms of mild dementia during testing with the Montreal Cognitive Assessment (MoCA), coin-in-hand forced-choice test, short digit span trials, Luria 3-step test and interlocking finger test. Family history of dementia was recorded.Results.In 50 participants aged 18–27, simulating dementia, mean MoCA score was 16 (SD 5.5, range 5–26). Delayed recall was the most frequently failed item (100%) and cube drawing least frequently failed (42%). Twenty-six percent failed forward three-digit span and 36% failed reverse two-digit span. On the coin-in-hand test, 32% scored at or below chance level. Inconsistent response patterns were common.Conclusions.Cognitively healthy young adults simulating mild dementia perform similarly to older adults with mild dementia, demonstrating beliefs that dementia is associated with significant global impairment, including attention, motor function, and letter vigilance, but preservation of cube drawing. Inconsistent response patterns were common. Contrary to expectation, family history of dementia did not influence performance. Two and three digit span showed particular promise as a bedside test for simulation. Further investigation will establish whether similar patterns of results are produced in individuals with functional cognitive symptoms.

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.

To our knowledge, circadian rhythms have not been examined in girls with polycystic ovarian syndrome (PCOS), despite the typical delayed circadian timing of adolescence, which is an emerging link between circadian health and insulin sensitivity (SI), and decreased SI in PCOS.

ObjectiveForeign accent syndrome (FAS) is widely understood as an unusual consequence of structural neurological damage, but may sometimes represent a functional neurological disorder. This observational study aimed to assess the prevalence and utility of positive features of functional FAS in a large group of individuals reporting FAS.MethodsParticipants self-reporting FAS recruited from informal unmoderated online support forums and via professional networks completed an online survey. Speech samples were analysed in a subgroup.ResultsForty-nine respondents (24 UK, 23 North America, 2 Australia) reported FAS of mean duration 3 years (range 2 months to 18 years). Common triggers were: migraine/severe headache (15), stroke (12), surgery or injury to mouth or face (6) and seizure (5, including 3 non-epileptic). High levels of comorbidity included migraine (33), irritable bowel syndrome (17), functional neurological disorder (12) and chronic pain (12). Five reported structural lesions on imaging. Author consensus on aetiology divided into, ‘probably functional (n=35.71%), ‘possibly structural’ (n=4.8%) and ‘probably structural’ (n=10.20%), but positive features of functional FAS were present in all groups. Blinded analysis of speech recordings supplied by 13 respondents correctly categorised 11 (85%) on the basis of probable aetiology (functional vs structural) in agreement with case history assignment.ConclusionsThis largest case series to date details the experience of individuals with self-reported FAS. Although conclusions are limited by the recruitment methods, high levels of functional disorder comorbidity, symptom variability and additional linguistic and behavioural features suggest that chronic FAS may in some cases represent a functional neurological disorder, even when a structural lesion is present.

Fairness and inclusion for women in sports administration will change the game for everyone. DEI is a team sport, but commitment, dedication, persistence, and investments from leadership are critical to creating inclusive environments. The authors wish to thank the organization WISE (Women in Sports and Events) for their contribution and to acknowledge Major League Soccer, the National Football League, and the National Hockey League for their efforts in helping to advance the research. [Extracted from the article]

IntroductionCurrently there is no standardized way to diagnose functional cognitive disorder (FCD) in clinical practice. We aimed to develop a bedside screening tool to differentiate between FCD and neurodegenerative causes of memory complaints.MethodsA Delphi methodology was used to obtain consensus based on expert opinion through a series of three consecutive rounds. International experts with an interest and experience in cognitive disorders and functional neurological disorders were selected. The first and second rounds included both clinical vignettes and a list of diagnostic clinical signs favoring a FCD diagnosis (obtained from a systematic review of the literature), to be ranked using a 7-point Likert scale. Qualitative and quantitative analysis were undertaken. Finally, experts reviewed the component items for which consensus had been achieved and provided recommendations for modifications to better discriminate between FCD and dementia.Results45 experts, from 12 different countries, participated in the first round. A retention rate of at least 80% was obtained in subsequent rounds. 47% of the participants diagnosed between 10 and 50 patients with FCD over the last year. 69% reported that FCD comprises between 5 and 30% of the patients with memory complaints seen in the clinic. 91.4% would be interested in using a newly developed resource of this kind with the patients. A checklist was built and adapted into a scale, based on 11 statements for which strong (discrepancy between the level of symptoms reported and observed everyday functioning; patient’s ability to detail memory complaints with specific examples; and variable and/or fluctuating cognitive symptoms; 2 points each), moderate (ability to detail the list of drugs and/or previous interactions with other doctors; history of a non-cognitive functional neurological disorder or somatic symptoms; 1 point each) or low consensus (patient more aware of the cognitive changes than others; normal/incongruent cognitive performance; absence of symptom progression; dating symptom onset with precision; presence of psychological stressors; and ability to answer compound questions; 1 point each) was achieved. There was poor inter-rater agreement (Fleiss’ kappa=.035, p<.000). Regarding the vignettes, there was a major consensus gap in diagnosing FCD (<50% agreement) and neurodegenerative syndromes including Alzheimer’s disease (60–95% agreement).ConclusionsThis 11-item checklist is a simple complementary clinical tool aiming to improve diagnostic accuracy and direct patients to early post-diagnostic treatment. Further retrospective and prospective validation will be needed before it can be used clinically. This study is part of a wider project trying to improve the diagnosis of FCD.

Objectives/AimsChronic pain is commonly reported as a comorbidity in patients with functional neurological disorder (FND) however the prevalence of FND in those presenting with chronic pain is unknown. We aimed to estimate 1) the prevalence of FND in patients seen at a chronic pain clinic and 2) how patients with chronic pain and comorbid FND differ from those without FND in terms of pain characteristics, psychiatric comorbidity, pain management and pain outcome.MethodsRetrospective electronic records review of consecutive new patients attending chronic pain clinics of 8 pain specialists in Lothian from the 1st of August 2019 to the 19thSeptember of 2019. Mean duration of follow up was 25 months. We recorded the clinical features, medication, management and outcome of chronic pain, any lifetime (up to November 2021) diagnoses of functional, FND and psychiatric disorders and undiagnosed neurological symptoms (where it was unclear if symptoms related to FND or another condition).ResultsOf 190 patients attending a chronic pain clinic, 32 (17%) had at least one lifetime diagnosis of FND and an additional 8 (4%) had undiagnosed neurological symptoms. FND diagnoses were functional limb weakness (8%), functional sensory disorder (8%), dissociative seizures (6%), functional cognitive disorder (5%), functional movement disorder (4%) and others (2%). Chronic primary pain (p<0.001), widespread chronic primary pain (p<0.00001) and pain with no precipitating trigger (p<0.01) were more common in pain patients with comorbid FND. A history of depression (p<0.001), anxiety (p<0.05) and suicide attempt (p<0.05) were also more common in these patients. However, patients with chronic pain and comorbid FND did not differ significantly from patients without FND in age, gender, prescribed analgesia (opiates and benzodiazepines) or pain outcome (25% vs 34% pain improved).ConclusionsFND was found in a surprisingly high 17% of new patients at a chronic pain clinic. This may be an underestimate based on an additional 4% of patients with undiagnosed neurological symptoms. Patients with chronic pain and FND are significantly more likely to have chronic primary pain compared to other pain patients but do not experience different pain management or outcome. These results provide further evidence of the important overlap between FND and chronic pain conditions.

ObjectivesThe term ‘brain fog’ is increasingly used in social and other media. But what is brain fog? What sort of experiences do people talk about when they talk about brain fog? And, in turn, what might this tell us about potential underlying pathophysiological mechanisms? In this study we examined first-person descriptions of brain fog in order to better understand a) the phenomenology of brain fog, and b) the causal attributions of those describing brain fog. We use this information to consider implications for clinical research.MethodsData were scraped from the social media platform Reddit using Python. Posts containing ‘brain fog’ were identified between 27thOctober 2021 and 3rd November 2021. Those not describing or discussing brain fog as a symptom or experience were excluded. Potentially identifying information was removed prior to analysis. We undertook thematic analysis of containing subreddits (topic-specific discussion forums), causal attributions, and discrete brain fog experiences.Results1663 posts including the term ‘brain fog’ were identified, of which 717 met inclusion criteria.44% (315/717) posts originated from subreddits concerned with illness and disease: including COVID-19 (87 posts), autoimmune, functional, neurodevelopmental, major psychiatric, and endocrine disorders. Brain fog was also discussed in subreddits about prescribed and non-prescribed drug use, and subreddits concerned with intentional restriction of masturbation (‘nofap’).141 first person descriptions of brain fog described overlapping concepts including: forgetfulness (51), difficulty concentrating (43), dissociative phenomena (34), perceived cognitive ‘slowness’ and excessive effort (26), communication difficulties (22), a feeling of ‘fuzziness’ or pressure in the head (10), and fatigue (9).570 posts described a perceived cause of brain fog, of which half attributed brain fog to illness or disease (282/570) (the most common single attribution being ‘long COVID’ in 59/570 (10%)), followed by psychiatric conditions in 38/570 (7%). The second most common single attribution of brain fog, in 24/570 (24%), was restriction or excessive masturbation.ConclusionsBrain fog is discussed on the Reddit social media platform in association with a wide range of illnesses, diseases, drugs, and activities. The term is used to describe heterogeneous experiences, which do not map in a straightforward way to the domains enquired about during a ‘cognitive’ clinical examination, but include experiences of dissociation, fatigue, and excessive cognitive effort. Encouraging detailed description of subjective experiences – moving away from a psychometric testing approach and towards a phenomenological approach – might open new routes into understanding cognitive difficulties in health and disease.