Search

Aneeta Saxena,1,2 Ellen Godena,1 Julie Maggio,1,3 David L Perez1,4 1Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 2Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA; 3Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA; 4Division of Neuropsychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USACorrespondence: Aneeta SaxenaMassachusetts General Hospital, Department of Neurology, 55 Fruit Street, Boston, MA 02114, USAEmail asaxena7@mgh.harvard.eduAbstract: Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create “rule-in” diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common “rule-in” neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.Keywords: functional movement disorder, dissociative seizures, conversion disorder, psychogenic, treatment, neuropsychiatry

Primary progressive aphasia (PPA) is a language predominant neurodegenerative disorder that has three recognized variants: nonfluent/agrammatic, semantic, and logopenic. This report describes a 60-year-old man who presented with a progressive decline in verbal output that does not fit the currently accepted PPA subtypes. The patient exhibited a paucity of verbal output and impaired phonemic fluency with minimal associated language, cognitive, or behavioral deficits. Focal cortical thinning/hypometabolism of the left superior frontal region and a cerebrospinal fluid profile not consistent with Alzheimer's disease pathology were identified. This case of isolated progressive dynamic aphasia extends the current boundaries of PPA diagnostic variants. [ABSTRACT FROM AUTHOR]

Background: Functional cognitive disorder (FCD) may be common after a concussion, and no evidence-based treatment options are available. The current study evaluated the feasibility of a novel cognitive-behavioural therapy (CBT) protocol tailored to FCD after concussion., Methods: Participants were randomised to CBT (n=11) or the current standard of care, cognitive rehabilitation (n=13). Both interventions consisted of eleven 50 min manualised videoconference sessions. CBT involved cognitive reappraisal and exposure-based strategies. Cognitive rehabilitation involved traditional memory compensation strategy training. Prespecified feasibility criteria were set for recruitment, perceived credibility, patient adherence, therapist protocol compliance and retention. The primary efficacy outcome was the Multifactorial Memory Questionnaire-Satisfaction (MMQ-S). The first five CBT completers completed a semistructured interview about their experience with the intervention., Results: Most feasibility benchmarks were met, as 86% of invited patients consented, 96% of participants rated their intervention as credible, participants attended 96% of sessions, therapists covered all essential content in 94% of sessions and 100% of participants completed the post-treatment evaluation. Both groups improved on the MMQ-S. Post-treatment MMQ-S scores were similar between groups (Cohen's d=-0.05 (95% CI [-0.86, 0.75])). Two themes resulted from the qualitative data analysis, which highlighted aspects of the CBT interventions that participants valued., Implications: This pilot trial supports the feasibility of CBT tailored to FCD after concussion and suggests that patients with FCD may benefit from either CBT or standard cognitive rehabilitation. A larger trial is needed to evaluate the efficacy of these interventions for FCD after concussion and potentially FCD in other clinical contexts., Trial Registration Number: NCT05581810., Competing Interests: JL received a Michael Smith Scholar Award. DLP has received honoraria for continuing medical education lectures; royalties from Springer for a textbook and honoraria from Elsevier for another textbook; is on the editorial boards of Brain and Behavior (paid), Epilepsy & Behavior, The Journal of Neuropsychiatry and Clinical Neurosciences, and Cognitive and Behavioral Neurology; receives funding from the Sidney R. Baer Jr. Foundation and NIH unrelated to this work and is on the FND Society Board, American Neuropsychiatric Association Advisory Council and the FND Hope International Medical Advisory Board. NDS has received research funding from the Canadian Institutes of Health Research, Canada Foundation for Innovation, Ontario Brain Institute, Weston Brain Institute and VGH+UBC Hospital Foundation. He has also received honoraria for continuing medical education lectures., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pathological health anxiety (PHA) (e.g., hypochondriasis and illness anxiety disorder) is common in medical settings and associated with increased healthcare costs. However, the psychological and neurobiological mechanisms contributing to the development and maintenance of PHA are incompletely understood., Methods: We performed a systematic review to characterize the mechanistic understanding of PHA. PubMed, PsycINFO, and Embase databases were searched to find articles published between 1/1/1990 and 12/31/2022 employing a behavioral task and/or physiological measures in individuals with hypochondriasis, illness anxiety disorder, and PHA more broadly., Results: Out of 9141 records identified, fifty-seven met inclusion criteria. Article quality varied substantially across studies, and was overall inadequate. Cognitive, behavioral, and affective findings implicated in PHA included health-related attentional and memory recall biases, a narrow health concept, threat confirming thought patterns, use of safety-seeking behaviors, and biased explicit and implicit affective processing of health-related information among other observations. There is initial evidence supporting a potential overestimation of interoceptive stimuli in those with PHA. Neuroendocrine, electrophysiology, and brain imaging research in PHA are particularly in their early stages., Limitations: Included articles evaluated PHA categorically, suggesting that sub-threshold and dimensional health anxiety considerations are not contextualized., Conclusions: Within an integrated cognitive-behavioral-affective and predictive processing formulation, we theorize that sub-optimal illness and health concepts, altered interoceptive modeling, biased illness-based predictions and attention, and aberrant prediction error learning are mechanisms relevant to PHA requiring more research. Comprehensively investigating the pathophysiology of PHA offers the potential to identify adjunctive diagnostic biomarkers and catalyze new biologically-informed treatments., Competing Interests: Declaration of competing interest D.L.P. has received royalties for a Springer Nature textbook on functional movement disorder; is a paid senior editor at Brain and Behavior; has received honoraria for a functional neurological disorder textbook and continuing medical education lectures; has received funding from the Sidney R. Baer Jr. Foundation unrelated to this work; and is on the editorial boards of The Journal of Neuropsychiatry & Clinical Neurosciences, Epilepsy & Behavior, and Cognitive and Behavioral Neurology. All other authors do not have any disclosures or other conflicts of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Brain imaging studies investigating grey matter in functional neurological disorder (FND) have used univariate approaches to report group-level differences compared with healthy controls (HCs). However, these findings have limited translatability because they do not differentiate patients from controls at the individual-level., Methods: 183 participants were prospectively recruited across three groups: 61 patients with mixed FND (FND-mixed), 61 age-matched and sex-matched HCs and 61 age, sex, depression and anxiety-matched psychiatric controls (PCs). Radial basis function support vector machine classifiers with cross-validation were used to distinguish individuals with FND from HCs and PCs using 134 FreeSurfer -derived grey matter MRI features., Results: Patients with FND-mixed were differentiated from HCs with an accuracy of 0.66 (p=0.005; area under the receiving operating characteristic (AUROC)=0.74); this sample was also distinguished from PCs with an accuracy of 0.60 (p=0.038; AUROC=0.56). When focusing on the functional motor disorder subtype (FND-motor, n=46), a classifier robustly differentiated these patients from HCs (accuracy=0.72; p=0.002; AUROC=0.80). FND-motor could not be distinguished from PCs, and the functional seizures subtype (n=23) could not be classified against either control group. Important regions contributing to statistically significant multivariate classifications included the cingulate gyrus, hippocampal subfields and amygdalar nuclei. Correctly versus incorrectly classified participants did not differ across a range of tested psychometric variables., Conclusions: These findings underscore the interconnection of brain structure and function in the pathophysiology of FND and demonstrate the feasibility of using structural MRI to classify the disorder. Out-of-sample replication and larger-scale classifier efforts incorporating psychiatric and neurological controls are needed., Competing Interests: Competing interests: DLP has received honoraria for continuing medical education lectures in FND; royalties from Springer for a functional movement disorder textbook and honoraria from Elsevier for a functional neurological disorder textbook; is on the editorial boards of Brain and Behavior (paid), Epilepsy & Behavior, The Journal of Neuropsychiatry and Clinical Neurosciences and Cognitive and Behavioral Neurology; has previously received funding from the Sidney R. Baer Jr. Foundation unrelated to this work and is on the FND Society Board, American Neuropsychiatric Association Advisory Council and the FND Hope International Medical Advisory Board. All other authors report no conflicts of interest/disclosures., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Limited research has directly investigated whether and how placebo effects can be harnessed for the treatment of functional neurological disorder (FND), despite a long-standing and controversial history of interest in this area., Methods: A small exploratory study was conducted with adults with a cognitive subtype of FND recruited from a single cognitive neurology center in the United States. Participants were given the expectation of receiving cranial stimulation that could benefit their memory symptoms; however, the intervention was sham transcranial magnetic stimulation (placebo). Outcomes included measures of short-term memory testing, subjective memory rating, and state anxiety before and after stimulation. After the study, the true objective and rationale for investigating placebo effects were explained in a scripted debriefing session. Acceptability of the study design and qualitative feedback were collected. Institutional ethics approval and signed consent were obtained., Results: Three patients (female, N=2; male, N=1; average age=57 years) were recruited. Outcome data were analyzed descriptively at the patient level. Trends of improvement in subjective memory rating, but not objective cognitive test scores, and decreases in state anxiety were observed. After the debriefing session, all patients found the study design to be acceptable (ratings of 70%, 90%, and 100%), and two of the three patients believed that withholding mechanistic information about the intervention was needed to leverage placebo effects as treatment., Conclusions: In the first study to prospectively investigate the feasibility of harnessing placebo effects for the treatment of FND, promising preliminary findings were obtained, and methods and resources for use in larger future studies are offered., Competing Interests: Dr. Perez has received honoraria for continuing medical education lectures; he has received royalties from Springer Nature; he has served on the editorial boards of Brain and Behavior, Epilepsy & Behavior, and the Journal of Neuropsychiatry and Clinical Neurosciences; and he has received funding from NIH and the Sidney R. Baer, Jr. Foundation. Dr. Pascual-Leone has served on the scientific advisory boards of Hearts Radiant, Magstim, MedRhythms, Neuroelectrics, Skin2Neuron, and TetraNeuron; he is co-founder of TI Solutions and cofounder and chief medical officer of Linus Health; and he is listed as an inventor on several issued and pending patents on the real-time integration of transcranial magnetic stimulation with electroencephalography and MRI, on applications of noninvasive brain stimulation in various neurological disorders, and on digital biomarkers of cognition and digital assessments for early diagnosis of dementia. The other authors report no financial relationships with commercial interests.

Behavioral neurology & neuropsychiatry (BNNP) is a field that seeks to understand brain-behavior relationships, including fundamental brain organization principles and the many ways that brain structures and connectivity can be disrupted, leading to abnormalities of behavior, cognition, emotion, perception, and social cognition. In North America, BNNP has existed as an integrated subspecialty through the United Council for Neurologic Subspecialties since 2006. Nonetheless, the number of behavioral neurologists across academic medical centers and community settings is not keeping pace with increasing clinical and research demand. In this commentary, we provide a brief history of BNNP followed by an outline of the current challenges and opportunities for BNNP from the behavioral neurologist's perspective across clinical, research, and educational spheres. We provide a practical guide for promoting BNNP and addressing the shortage of behavioral neurologists to facilitate the continued growth and development of the subspecialty. We also urge a greater commitment to recruit trainees from diverse backgrounds so as to dismantle persistent obstacles that hinder inclusivity in BNNP-efforts that will further enhance the growth and impact of the subspecialty. With rapidly expanding diagnostic and therapeutic approaches across a range of conditions at the intersection of neurology and psychiatry, BNNP is well positioned to attract new trainees and expand its reach across clinical, research, and educational activities., Competing Interests: J.R.B. has received honoraria for continuing medical education (CME) lectures in behavioral neurology & neuropsychiatry (BNNP) and from Novo Nordisk. He has received funding from the National Institutes of Health (NIH), Dementia Alliance of North Carolina, and Alzheimer’s Association for work unrelated to this project. S.J.H. has received honoraria for CME lectures in BNNP. She has received funding from the Sidney R. Baer Jr. Foundation unrelated to this project. S.B. is a partner in and author for Brain Educators LLC, a neuropsychiatry education publisher. He has received honoraria for CME lectures in BNNP and receives a stipend as a psychiatry director of the American Board of Psychiatry and Neurology. B.F.B. receives author royalties from Cambridge University Press; honoraria for scientific advisory board activities for the Tau Consortium, funded by the Rainwater Charitable Foundation; and institutional research grant support from NIH and for clinical trials from Alector, Biogen, Transposon, Cognition Therapeutics, EIP Pharma, and GE Healthcare—all unrelated to this project. A.E.B. receives author royalties from Oxford University Press and Elsevier; investigator-initiated grants from the Alzheimer’s Association, VoxNeuro, and Bristol Myers Squibb; and consulting honorarium from Eli Lilly—all unrelated to this project. M.D.G. has consulted for Gerson Leherman Group and Reata Pharmaceuticals and receives research support from NIH, the National Institute of Neurological Disorders and Stroke (NINDS), and the Michael J. Homer Family Fund. A.E.H. receives honoraria from the American Heart Association as editor-in-chief of Stroke , and from Elsevier as associate editor of PracticeUpdate Neurology , unrelated to this project. S.K.H. has received honoraria for CME lectures from the American Academy of Neurology (AAN) and the Lewy Body Dementia Association. She has received research funding from NIH and the Michael J. Fox Foundation for Parkinson’s Research. I.K. receives funding from NIH and NINDS. J.D.S. is site principal investigator for Biohaven Pharmaceuticals clinical trials NCT03701399, NCT02960893, and NCT03952806; receives royalties from Oxford University Press, Elsevier, MacKeith Press, and Springer; and is the inventor of the Brief Ataxia Rating Scale, Cerebellar Cognitive Affective/Schmahmann Syndrome Scale, Patient Reported Outcome Measure of Ataxia, and Cerebellar Neuropsychiatry Rating Scale, which are licensed to the General Hospital Corporation. C.C.W. has received honoraria for creating educational content for the AAN. R.H.H. is a paid member of the board of trustees for the McKnight Brain Research Foundation and has received funding from NIH, the Department of Defense, and the Chan Zuckerberg Initiative for work unrelated to this project. D.L.P. has received honoraria for CME lectures in BNNP, royalties from Springer for a functional movement disorder textbook, and honoraria from Elsevier for a functional neurological disorder textbook, and is a paid member of the Brain and Behavior editorial board. He has received funding from NIH and the Sidney R. Baer Jr. Foundation unrelated to this project. The remaining authors declare no conflicts of interest., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background and Objectives: Occupational therapy (OT) consensus recommendations and articles outlining a sensory-based OT intervention for functional neurological disorder (FND) have been published. However, limited research has been conducted to examine the efficacy of OT interventions for FND. We performed a retrospective cohort study aimed at independently replicating preliminarily characterized sensory processing difficulties in patients with FND and reporting on clinical outcomes of a sensory-based OT treatment in this population. We hypothesized that (1) a history of functional seizures, anxiety, and/or post-traumatic stress disorder would be associated with increased sensory processing difficulties and (2) the number of OT treatment sessions received would positively relate to clinical improvement., Methods: Medical records were reviewed for 77 consecutive adults with FND who received outpatient, sensory-based OT care. Data from the Adolescent/Adult Sensory Profile characterized self-reported sensory processing patterns across 4 quadrants (low registration, sensory sensitivity, sensory seeking, and sensory avoidance) in this population. Following univariate screenings, multivariate linear regression analyses were performed to identify neuropsychiatric characteristics associated with discrete sensory processing patterns. Clinical improvement was quantified using an estimated, clinician-determined improvement rating ("improved" vs "not improved"), and relationships between clinical participation, baseline neuropsychiatric factors, and outcomes were investigated., Results: Patients with FND reported sensory processing patterns with elevated scores in low registration, sensory sensitivity, and sensation avoidance compared with normative values; differences in sensory processing scores were not observed across FND subtypes (i.e., motor, seizure, and speech variants). In linear regression analyses, lifetime history of an anxiety disorder, history of migraine headaches, current cognitive complaints, and a comorbid major neurologic condition independently predicted individual differences in sensory processing scores. Following a sensory-based OT intervention, 62% of individuals with FND were clinician determined as "improved." In a multivariate logistic regression analysis controlling for baseline characteristics associated with improvement ratings, number of treatment sessions positively correlated with clinical improvement., Discussion: These findings support the presence of sensory processing difficulties in patients with FND and provide Class IV evidence for the efficacy of an outpatient, sensory-based OT intervention in this population. Controlled prospective trials are warranted., Competing Interests: D.L. Perez has received honoraria for continuing medical education lectures on functional neurological disorder, has received royalties from Springer for a functional movement disorder textbook, is a paid senior editor of Brain and Behavior, is on the editorial board of The Journal of Neuropsychiatry and Clinical Neurosciences and Epilepsy & Behavior, and has received funding from the NIH and Sidney R. Baer Jr. Foundation unrelated to this work. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp., (© 2024 American Academy of Neurology.)

The contemporary neuroscience understanding of the brain as an active inference organ supports that our conscious experiences, including sensorimotor perceptions, depend on the integration of probabilistic predictions with incoming sensory input across hierarchically organized levels. As in other systems, these complex processes are prone to error under certain circumstances, which may lead to alterations in their outcomes (i.e., variations in sensations and movements). Such variations are an important aspect of functional neurological disorder, a complex disorder at the interface of brain-mind-body interactions. Thus, predictive processing frameworks offer fundamental mechanistic insights into the pathophysiology of functional neurological disorder. In recent years, many of the aspects relevant to the neurobiology of functional neurological disorder - e.g., aberrant motor and sensory processes, symptom expectation, self-agency, and illness beliefs, as well as interoception, allostasis, and emotion - have been investigated through the lens of predictive processing frameworks. Here, we provide an overview of the current state of research on predictive processing and the pathophysiology of functional neurological disorder., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

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., (© 2024 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Competing Interests: Dr. Perez has received honoraria for continuing medical education lectures on functional neurological disorder; he has received royalties from Springer for a functional movement disorder textbook; he is on the editorial boards of The Journal of Neuropsychiatry and Clinical Neurosciences, Epilepsy & Behavior, and Brain and Behavior; and he has received funding from NIH and the Sidney R. Baer, Jr. Foundation. The other authors report no financial relationships with commercial interests.

Telehealth and telemedicine have encountered explosive growth since the beginning of the COVID-19 pandemic, resulting in increased access to care for patients located far from medical centers and clinics. Subspecialty clinicians in behavioral neurology & neuropsychiatry (BNNP) have implemented the use of telemedicine platforms to perform cognitive examinations that were previously office based. In this perspective article, BNNP clinicians at Massachusetts General Hospital (MGH) describe their experience performing cognitive examinations via telemedicine. The article reviews the goals, prerequisites, advantages, and potential limitations of performing a video- or telephone-based telemedicine cognitive examination. The article shares the approaches used by MGH BNNP clinicians to examine cognitive and behavioral areas, such as orientation, attention and executive functions, language, verbal learning and memory, visual learning and memory, visuospatial function, praxis, and abstract abilities, as well as to survey for neuropsychiatric symptoms and assess activities of daily living. Limitations of telemedicine-based cognitive examinations include limited access to and familiarity with telecommunication technologies on the patient side, limitations of the technology itself on the clinician side, and the limited psychometric validation of virtual assessments. Therefore, an in-person examination with a BNNP clinician or a formal in-person neuropsychological examination with a neuropsychologist may be recommended. Overall, this article emphasizes the use of standardized cognitive and behavioral assessment instruments that are either in the public domain or, if copyrighted, are nonproprietary and do not require a fee to be used by the practicing BNNP clinician., Competing Interests: Dr. Camprodon has served on the scientific advisory boards for Hyka and Flow Neuroscience, and she has served as a consultant for Mifu Technologies and Neuroelectrics. Dr. Newhouse has served as a consultant for Musculo. Dr. Perez has received honoraria for continuing medical education lectures; he has received royalties from Springer Nature; he serves on the editorial boards of Brain and Behavior, Epilepsy & Behavior, and The Journal of Neuropsychiatry and Clinical Neurosciences; and he has received funding from NIH and the Sidney R. Baer Jr. Foundation. Dr. Razafsha is a shareholder with Masimo Corporation. Dr. Schmahmann is site principal investigator for Biohaven (NCT03701399, NCT02960893, and NCT03952806); he has received royalties from Elsevier, MacKeith Press, Oxford University Press, and Springer; and he holds a license with the General Hospital Corporation for the Brief Ataxia Rating Scale, the Cerebellar Cognitive Affective/Schmahmann syndrome scale, the Cerebellar Neuropsychiatry Rating Scale, and the Patient-Reported Outcome Measure of Ataxia. The other authors report no financial relationships with commercial interests.

Obesity is associated with an overall increased risk of morbidity and mortality. However, in patients with critical illness, sepsis, and acute respiratory distress syndrome, obesity may be protective, termed "the obesity paradox." This is a systematic literature review of articles published from 2000 to 2022 evaluating complications and mortality in adults with respiratory failure on veno-venous extracorporeal membrane oxygenation (VV ECMO) based on body mass index (BMI). Eighteen studies with 517 patients were included. Common complications included acute renal failure (175/377, 46.4%), venous thrombosis (175/293, 59.7%), and bleeding (28/293, 9.6%). Of the six cohort studies, two showed improved mortality among obese patients, two showed a trend toward improved mortality, and two showed no difference. Comparing all patients in the studies with BMI of less than 30 to those with BMI of greater than or equal to 30, we noted decreased mortality with obesity (92, 37.1% of BMI <30 vs. 30, 11% of BMI ≥30, p ≤ 0.0001). Obesity may be protective against mortality in adult patients undergoing VV ECMO. Morbid and super morbid obesity should not be considered a contraindication to cannulation, with patients with BMI ≥ 80 surviving to discharge. Complications may be high, however, with higher rates of continuous renal replacement therapy and thrombosis among obese patients., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2023.)

Objective: Patients with functional neurological disorder involving the motor system (eg, functional weakness, functional gait) may acutely present to the hospital for new-onset symptoms. For some, symptoms may remain severe enough at the time of hospital discharge to qualify for an inpatient rehabilitation facility stay., Design: Data were extracted via retrospective chart review on functional neurological disorder patients ( N = 22) admitted to an inpatient rehabilitation facility between September 2019 and May 2022. Demographic and clinical data, including admission and discharge physical and occupational therapy measurements on the Inpatient Rehabilitation Facility Patient Assessment Instrument, were recorded and analyzed., Results: Symptom duration was less than 1 wk for nearly two thirds of the cohort. After an approximately 2-wk length of stay, patients showed statistically significant changes in admission to discharge measures of self-care, transfers, ambulation, and balance. More than 95% of patients were able to be discharged home. The presence or absence of comorbid depression, anxiety, or posttraumatic stress disorder did not impact outcomes., Conclusions: For a subset of patients with persistent motor symptoms after an acute hospital admission for a new diagnosis of functional neurological disorder, a relatively short inpatient rehabilitation facility stay was associated with significant clinical gains., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.L.P. has received honoraria for continuing medical education lectures in FND; royalties from Springer for the textbook Functional Movement Disorder and from Elsevier for the textbook Functional Neurological Disorder; is on the editorial boards of Brain and Behavior (paid), Epilepsy & Behavior, and The Journal of Neuropsychiatry and Clinical Neurosciences; has received funding from the NIH and Sidney R. Baer Jr. Foundation for FND research; and is on the FND Society board and American Neuropsychiatric Association advisory council. T.R.N. does expert witness work in personal injury and clinical negligence cases of FND and other disorders; has received financial support for lectures from the FND Society; receives royalties from CRC Press for The Pocket Prescriber textbook series and from Springer for the textbook Functional Movement Disorder; has received grant funding, including for studies related to FND, from the UK National Institute for Health and Care Research (NIHR) and the Medical Research Council (MRC); is co-chair of the FNDS patient liaison committee and on the medical advisory boards of the charities FND Hope UK and FND Action and a trustee of FND Action. A.A.A.P. honoraria from Cobel Daruo; royalty: Oxford University Press (Book publication). M.B. receives royalties from CRC Press for Pocket Prescriber Psychiatry 2E and has been awarded fellowships from NIHR and the Wellcome Trust for studies on FND. A.J.C. paid associate editor of Journal of Neurology, Neurosurgery and Psychiatry; provides expert testimony in court on a range of neuropsychiatric topics including FND; and is on the FND Society board. Q.D. does medical expert reporting in personal injury and clinical negligence cases, including in cases of FND. M.J.E. does medical expert reporting in personal injury and clinical negligence cases, including in cases of FND; has shares in Brain & Mind (which provides neuropsychiatric and neurological rehabilitation in the independent medical sector, including in people with FND); has received financial support for lectures from the International Parkinson’s and Movement Disorders Society and the FND Society; receives royalties from Oxford University Press for his book The Oxford Specialist Handbook of Parkinson’s Disease and Other Movement Disorder; has received honoraria for medical advice to Teva Pharmaceuticals; receives grant funding, including for studies related to FND, from the National Institute for Health and Care Research (NIHR) and the Medical Research Council (MRC); is an associate editor of the European Journal of Neurology; is a member of the international executive committee of the International Parkinson’s and Movement Disorders Society and the FND Society board; and is on the medical advisory boards of the charities FND Hope UK and Dystonia UK. A.J.E. has received grant support from the NIH and the Michael J Fox Foundation; personal compensation as a consultant/scientific advisory board member for Neuroderm, Amneal, Acadia, Avion Pharmaceuticals, Acorda, Kyowa Kirin, Supernus (formerly, USWorldMeds), and Herantis Pharma; honoraria for speakership for Avion, Amneal, and Supernus; royalties from Lippincott Williams & Wilkins, Cambridge University Press, and Springer; cofounded REGAIN Therapeutics; co-inventor of the patent “Compositions and methods for treatment and/or prophylaxis of proteinopathies”; and is on the FND Society board. M.H. is an inventor of a patent held by NIH for the H-coil for magnetic stimulation for which he receives license fee payments from the NIH (from Brainsway); is on the Medical Advisory Boards of Brainsway, QuantalX, and VoxNeuro; has consulted for Janssen Pharmaceuticals, and is on the FND Society board. R.A.A.K. receives royalties from Guilford press for a book chapter related to FND; grant funding from the National Health and Medical Research Council, The Medical Research Future Fund for research in FND; provides expert medico-legal opinions on neuropsychiatric disorders, including FND; is on the board of the International Neuropsychiatry Association. M.A.J.T reports grants from the Netherlands Organization for Health Research and Development ZonMW Topsubsidie (91218013) and ZonMW Program Translational Research(40–44600-98–323); has received a European Fund for Regional Development from the European Union (01492947) and a European Joint Programme on Rare Diseases (EJP RD) Networking Support Scheme; furthermore, from the province of Friesland, the Stichting Wetenschapsfonds Dystonie and unrestricted grants from Actelion, Ipsen and Merz. W.C.L. has served on the editorial boards of Epilepsia, Epilepsy & Behavior; Journal of Neurology, Neurosurgery and Psychiatry, and The Journal of Neuropsychiatry and Clinical Neurosciences; 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 (EF), Brown University and the Siravo Foundation; has served on the Epilepsy Foundation New England Professional Advisory Board, the FND Society Board, the American Neuropsychiatric Association advisory council; has received honoraria for the AES Annual Meeting; 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. C.W.M. has received honoraria for continuing medical education lectures in FND, royalties from Springer for a textbook on functional movement disorder, and has received grant support from the Parkinson’s Foundation, Alzheimer’s Association and the Stony Brook Biomedical Sciences Innovation Fund unrelated to this work. J. P. Staab is supported by grant W81XWH1810760 from the US Department of Defense. J.S. royalties from UpToDate and carries out expert witness work in relation to FND; runs a free website for people with FND, www.neurosymptoms.org; and is on the FND Society board. J.P. Szaflarski, funding: NIH, NSF, DoD, Shor Foundation for Epilepsy Research, UCB Biosciences, NeuroPace Inc., SAGE Therapeutics Inc., Serina Therapeutics Inc., LivaNova Inc., Greenwich Biosciences Inc., Biogen Inc., Eisai Inc., State of AL; Consulting/Advisory Boards: PureTech Health, Biopharmaceutical Research Company, LivaNova Inc., UCB Pharma, AdCel Pharma, iFovea Inc; Editor-in-Chief, Epilepsy & Behavior Reports (paid); Editorial board member for Epilepsy & Behavior, Journal of Epileptology (associate editor), Journal of Medical Science, and Folia Medica Copernicana; provided expert opinion in medico-legal cases including of FND; has served on the Alabama State Medical Cannabis Study Commission (nominated by Gov. Ivey); serves on the Alabama Medical Cannabis Commission (2021–2025; nominated by Dr. Scott Harris, State Health Officer). S.A. is on the FND Society board.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a disabling long-term condition of unknown cause. The National Institute for Health and Care Excellence (NICE) published a guideline in 2021 that highlighted the seriousness of the condition, but also recommended that graded exercise therapy (GET) should not be used and cognitive-behavioural therapy should only be used to manage symptoms and reduce distress, not to aid recovery. This U-turn in recommendations from the previous 2007 guideline is controversial.We suggest that the controversy stems from anomalies in both processing and interpretation of the evidence by the NICE committee. The committee: (1) created a new definition of CFS/ME, which 'downgraded' the certainty of trial evidence; (2) omitted data from standard trial end points used to assess efficacy; (3) discounted trial data when assessing treatment harm in favour of lower quality surveys and qualitative studies; (4) minimised the importance of fatigue as an outcome; (5) did not use accepted practices to synthesise trial evidence adequately using GRADE (Grading of Recommendations, Assessment, Development and Evaluations trial evidence); (6) interpreted GET as mandating fixed increments of change when trials defined it as collaborative, negotiated and symptom dependent; (7) deviated from NICE recommendations of rehabilitation for related conditions, such as chronic primary pain and (8) recommended an energy management approach in the absence of supportive research evidence.We conclude that the dissonance between this and the previous guideline was the result of deviating from usual scientific standards of the NICE process. The consequences of this are that patients may be denied helpful treatments and therefore risk persistent ill health and disability., Competing Interests: Competing interests: PW was a coauthor of trials of both graded exercise therapy and cognitive behaviour therapy, including the PACE trial, is a trustee of the Voluntary Hospital of St Bartholomew’s Charity, was a previous member of Independent Medical Experts Group, which advises the UK MoD on its Armed Forces Compensation Scheme, and receives personal consultancy fees from Swiss Re reinsurance company. BA was a centre leader in the PACE trial. AJC reports grants from NIHR (Physio 4 FMD) and CSO (Long Covid Cognitive phenotyping). AJC is a paid associate editor of JNNP and unpaid president elect of the Functional Neurological Disorders Society (FNDS), he gives expert testimony in court on a range of neuropsychiatric topics on a 50% claimant 50%: defender basis. He is the author of a self-help book based on CBT principles for treatment of FND (no royalties taken). DJC declares grants from Pfizer and Aptinyx; consulting fees from AbbVie, Allergan Sales, Heron Therapeutics, Eli Lilly and Company, Aptinyx, H. Lundbeck A/S, Neumentum, Pfizer, Regeneron Pharmaceuticals, Samumed, Swing Therapeutics, Tonix Pharmaceuticals, Virios Therapeutics. Fees from Fasken Martineau DuMoulin, Kellogg, Hansen, Todd, Figel & Frederick, PLLC, Marks & Clerk Law, Nix Patterson, Pfizer, Zuber Lawler & Del Duca. JC reports consulting fees from Bial, and honoraria from Janssen, Bial and Brittania. BAD reports NIH R13 infrastructure grant for 2022 Functional Neurological Disorders Society meeting in Boston. TC was co-investigator of several trials of behavioural interventions for CFS/ME, including the PACE trial, has received royalties for several books and book chapters on CFS/ME and received payments for workshops on CBT for CFS/ME. BAD is on the board of directors of the FNDS and receives royalties from Oxford University Press for 'Psychogenic Nonepileptic Seizures: Towards the Integration of Care'. She does paid consultancy for Bioserenity (EEG interpretations) and Best Doctors (clinical consultations). She received support to attend the American Epilepsy Society Board of Directors meeting in 2021. She chairs the data safety monitoring board of the DSMB NIH-ESETT trial 2015–2019, and received travel expenses to attend the American Epilepsy Society Board of Directors FNDS meeting and Epilepsy Foundation of New England PAB. MJE reports royalties from Oxford University Press for the book 'The Oxford Specialist Handbook of Movement Disorders', consulting fees from UCB (personal) and Merz Pharma (to his institution), honoraria from the International Parkinson’s Disease and Movement Disorder Society, medicolegal fees for personal injury and clinical negligence cases, support to attend meetings from the FNDS, leadership roles in International Parkinson’s Disease and Movement Disorder Society and Dystonia UK, and is a medical board member of FND Action and FND Hope, and board member of the FNDS. JE was the President of the Faculty of Sport and Exercise Medicine at the time of the Royal College of Physicians’ review of this guideline and submitted comments on behalf of the Faculty. He is Medical Director of a company which occasionally manages patients with CFS/ME. AJE has received grant support from the NIH and the Michael J Fox Foundation, personal compensation as a consultant/scientific advisory board member for Neuroderm, Neurocrine, Amneal, Acadia, Acorda, Bexion, Kyowa Kirin, Sunovion, Supernus (formerly, USWorldMeds), Avion Pharmaceuticals, and Herantis Pharma, and publishing royalties from Lippincott Williams & Wilkins, Cambridge University Press, and Springer. He received an honorarium from Avion. He cofounded REGAIN Therapeutics (a biotech start-up developing nonaggregating peptide analogues as replacement therapies for neurodegenerative diseases) and is co-owner of a patent that covers synthetic soluble nonaggregating peptide analogues as replacement treatments in proteinopathies. PF declares consulting fees from FADL Forlag, Munksgaard, Ny Nordisk Forlag and Arnold Busk, an honorarium from Lundbeck Pharma,and medicolegal fees from Retslægerådet. SF was a co-founding member of the GRADE working group and a member of the GRADE guidance group. She has been engaged in debates related to the evidence regarding CFS/ME for many years from a biopsychosocial perspective. PGlasziou declares an NHMRC Investigator Award: 'Neglected Problems in Health Care' supporting his salary; grants from the National Heart Foundation, Commonwealth Department of Health and WHO for work unconnected to this paper, and is a board member (unpaid) for Therapeutic Guidelines. IH has an NRS Fellowship from CSO, has been paid for medicolegal consultations, receives travel expenses for attending medical conferences and one honorarium from Bristol NHS Neurology Department, and is on the board of Fowler’s syndrome UK Charity. WH was a member of the 2007 NICE Guideline Development Group, and is Chief Medical Officer of LV=, an insurance company. PH was part of the steering committee of the German clinical practice guideline on functional somatic symptoms. MH reports fees for medicolegal expert court reports (none concern CFS/ME). HK reports grants from ZonMw, Stichting NKCV, MS Research, and Dutch Cancer Society, was coauthor of trials of cognitive behaviour therapy, reports royalties for a published treatment manual for CBT for fatigue in CFS/ME, and an honorarium for a lecture from Intercept Pharma Deutschland. A Lehn is an unpaid director of the FNDS. AL reports grants for investigator initiated research grants from Gilead Sciences, AbbVie and Sequiris. AM has been on a trial steering committee for a trial of graded exercise therapy, was formerly the Chair of the British Association for CFS and ME (BACME) and Principal Medical Adviser for Action for ME. IM has been paid honoraria by The@WorkPartnership for lectures on the occupational health management approach to managing long-term conditions (including CFS/ME) in the workplace, is the Academic Dean of the Faculty of Occupational Medicine and commented on the NICE guidelines on the management of CFS/ME on behalf of the Faculty. MM received an honorarium for a lecture in 2020 for ViiV, received financial support to attend the EACS 2021 conference (virtual) and ViiV EACS 2019 conference, and was a centre co-lead for the PACE trial. IN reports research grants received from NIHR and MRC to conduct clinical trials on complex interventions, not specific to CFS/ME, has served on several Data Safety Committee as an independent member for trials on complex interventions, one of which related to CFS/ME, and is Co-Chair of Wellcome Trust/Indian Alliance DBT Team Science Grant and Clinical and Public Health Research Centers Grants Committee. DLP reports grants from the National Institutes of Health and Sidney R. Baer Jr. Foundation for work unrelated to this paper, has received honoraria for continuing medical education lectures at Harvard Medical School and the American Academy of Neurology, royalties from Springer Nature for a textbook on Functional Movement Disorder, is a member of the Board of Directors of the FNDS, senior (paid) editor of Brain and Behavior and is an Editorial Board Member of Epilepsy & Behavior. WP reports occasional paid lectures pertaining to FND (most payments donated to charity), has received fees for expert testimony in court on a range of neurological topics including FND, is a board member of FND Hope and FND Action, and is on the board of directors of the BNPA. MR reports a grant from Elsevier, royalties from Oxford University Press, honoraria from UCB Pharma, LivaNova, Eisai, and Angellini and sits on a data safety monitoring board for IqVia Medtech. WR reports grants from the German Research Foundation, royalties from books and fees for German legal opinions. AS was a member of the 2007 NICE Guideline Development Group for CFS/ME (CG53)]. TS reports being a member of the Board of Directors and Membership and Liaisons Committee of the FNDS and being a member of the Functional Movement Disorders Study Group (Movement Disorders Society). MS was a co-principal investigator for the PACE trial and has led a trial of CBT for CFS/ME. He is current President of the European Association of Psychosomatic Medicine Current (unpaid) and was the previous President of the Academy of Consultation Liaison Psychiatry (unpaid). BS is a Council Member of the Association of British Neurologists and Medical Expert Committee member of FND Hope UK. JS reports grants from Scottish Government and NIHR; royalties from UptoDate, the Donald Baxter Lecture Award, Montreal, titled 'Multiple Sclerosis at the limits', personal fees from expert witness work, Secretary FNDS, Medical Advisor FND Hope, Medical Advisor FND Action, running a self-help website for patients with FND. DTW reports consulting fees for expert opinions on patients in a prolonged disorder of consciousness, fees for occasional medicolegal and personal injury cases, member of NIHR grant Programme Supervisory Committee of a trial of vocational rehabilitation after head injury, Deputy Secretary to British Society of Physical and Rehabilitation Medicine (unpaid) and is employed at a nursing home where he sees 2-3 patients with functional disorders. SCW reports honoraria from two talks on psychological impacts of COVID to Swiss Re during the pandemic, but neither covered CFS nor Long Covid. He is on the Board of the ESRC and am also a member of the Judicial Appointments Commission for which he receives renumeration. None are relevant to this paper. SCW is also on the Board of the South London and Maudsley Foundation NHS Trust for which he receives no renumeration. SCW reports receiving grants to research CFS and has published over 150 papers on this subject, including being an author on several RCTs relevant to this submission, but none within the last 36 months. VW is Head of the Collaborative on Fatigue Following Infection (COFFI) (unpaid). AZ reports fees for expert witness medicolegal reports, but not in cases specifically focused on CFS/ME. No other authors declared any relevant competing interests., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Dividing the brain-mind into the specialized fields of neurology and psychiatry has produced many granular advantages, but these silos have imposed barriers to comprehensively understanding and contextualizing the fundamentals governing mental life and its maladies. Scientific inquiry into these fundamentals cannot reach its full potential without interdigitating the boundaries of two specialties of the same organ for both scholarship and clinical practice. We propose that to truly integrate disorders of the brain and the mind for research and clinical care, we must carefully reexamine the classification of its disorders (nosology) as an instrument to develop a coherent pathological and psychological framework. We call on professional organizations from neurology, psychiatry, behavioral neurology, neuropsychiatry, neuropsychology, and other relevant subspecialties (eg, geriatric psychiatry) to convene a multidisciplinary task force to define the current classification principles of their subspecialties and work toward developing an integrated nosology. The effect of a shared classification system, which we acknowledge is a difficult proposition philosophically and politically, would have transformative potential across educational, clinical, scientific, programmatic, and sociocultural realms. If accomplished, this initiative would provide a definitive step toward reducing stigma (and promoting reimbursement parity) for the full spectrum of complex brain disorders (regardless of traditional neurologic vs psychiatric conceptualizations)., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Psychiatric comorbidities such as depression, anxiety, and personality disorders are common in patients with functional limb weakness/paresis (FND-par). The impact of these conditions on the prognosis of FND-par has not been systematically reviewed. The aim of this study was to identify a potential prognostic effect of comorbid depression, anxiety, and/or personality disorder on prognosis in patients with FND-par., Methods: A systematic review was performed to identify studies that reported measures of baseline depression, anxiety, and/or personality disorder, and physical disability. An individual patient data meta-analysis was subsequently performed., Results: Eight studies comprising 348 individuals were included (7 prospective cohorts; 1 case-control study). There was heterogeneity in sample size, follow-up duration, and treatment modality. Depression and anxiety were present in 51.4% and 53.0% of FND-par patients, respectively. In individuals whose FND-par improved, there was no significant difference between those with versus without depression (52.6% vs 47.4%, p = 0.69) or those with versus without anxiety (50.3% vs 49.7%, p = 0.38). Meta-analysis showed no clear impact of baseline depression or anxiety per se [pooled OR for depression 0.85 (95%CI 0.50-1.45; p = 0.40) and anxiety 0.84 (95%CI 0.51-1.38; p = 0.91)]; and of depression or anxiety severity [pooled OR for depression 1.23 (95%CI 0.63-2.39; p = 0.91) and anxiety 1.40 (95%CI 0.70-2.78; p = 0.58)] on FND-par outcome. Insufficient data were available to assess the impact of personality disorders., Conclusion: We found no evidence that depression or anxiety influenced outcome in FND-par. Large-scale, prospective studies in FND-par, and other FND subtypes, are needed to fully contextualize the impact of concurrent mental health concerns on outcomes., Competing Interests: Declaration of Competing Interest David L. Perez has received honoraria for continuing medical education lectures on functional neurological disorder, royalties from Springer Nature for a functional movement disorder textbook, is a paid senior editor at Brain and Behavior, and has received funding from the NIH and the Sidney R. Baer Jr. Foundation unrelated to this work. Jon Stone reports honoraria from UptoDate, personal fees from expert witness work, grants from National Research Scotland and runs a self-help website for patients with Functional Neurological Disorder. He is medical advisor to FND Hope, FND Hope UK and FND Action, and secretary of the FND society. All other authors do not report any relevant conflicts of interest / disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Functional neurological disorder (FND) is a neuropsychiatric condition. In this field, prospective psychotherapy trials and consensus recommendations for physiotherapy, occupational therapy, and speech language therapy have been published. However, significant clinical complexities remain. "Rule in" signs - while critical for making a positive diagnosis - do not equate to a personalized treatment plan in many instances. Here, we propose that the neuropsychiatric assessment and real-time development of a work-in-progress biopsychosocial clinical formulation aids the development of a patient-centered outpatient treatment plan. This precision medicine approach is based on the literature, expert opinions and our clinical experience working in an interdisciplinary FND service., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Functional neurologic disorder (FND) is commonly encountered across outpatient and inpatient medical settings. Given the potential for a high burden of disability in some patients and mounting evidence for the efficacy of FND-specific multidisciplinary treatment services, expanding clinical services for this population is a necessity. In this perspective article, we discuss considerations for creating FND services, including the types of services that exist, how to start, how to identify appropriate referrals, and how to develop and monitor individualized treatment plans. In addition, we discuss how this effort can be done sustainably - balancing patient needs with limited healthcare resources., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To describe the current literature on functional neurological disorder and functional somatic syndromes among sexual and gender minority people (SGM)., Methods: A search string with descriptors of SGM identity and functional disorders was entered into PubMed, Embase, Web of Science, PsycInfo, and CINAHL for articles published before May 24, 2022, yielding 3121 items entered into Covidence, where 835 duplicates were removed. A neurologist and neuropsychiatrist screened titles and abstracts based on predefined criteria, followed by full-text review. A third neurologist adjudicated discrepancies. Eligible publications underwent systematic data extraction and statistical description., Results: Our search identified 26 articles on functional disorders among SGM people. Most articles were case (13/26, 46%) or cross-sectional (4/26, 15%) studies. Gender minority people were represented in 50% of studies. Reported diagnoses included fibromyalgia (n = 8), functional neurological disorder (n = 8), somatic symptom disorder (n = 5), chronic fatigue syndrome (n = 3), irritable bowel syndrome (n = 2), and other functional conditions (n = 3). Three cohort studies of fibromyalgia or somatic symptom disorder reported an overrepresentation of gender minority people compared to cisgender cohorts or general population measures. Approximately half of case studies reported pediatric or adolescent onset (7/13, 54%), functional neurological disorder diagnosis (7/13, 54%), and symptom improvement coinciding with identity-affirming therapeutic interventions (7/13, 58%)., Conclusion: Despite a methodologically rigorous literature search, there are limited data on functional neurological disorder and functional somatic syndromes among SGM people. Several studies reported increased prevalence of select conditions among transgender people. More observational studies are needed regarding the epidemiology and clinical course of functional disorders among SGM people., Competing Interests: Declaration of Competing Interest All authors have completed the ICMJE Unified Competing Interest form. The following authors have no disclosures to report: Dr. Fusunyan, Mr. Stave, Student Dr. Roldán, and Dr. Maschi. Dr. Lerario has served as plaintiff expert witness for Weiss Law, PC and receives consultancy payments regarding transgender neurological health care from medical colleges and universities within the US. Dr. Keuroghlian reports receiving textbook royalties from McGraw Hill. Dr. Turban reports receiving textbook royalties from Springer Nature and expert witness payments from The American Civil Liberties Union and Lambda Legal. He has received a pilot research award for general psychiatry residents from The American Academy of Child & Adolescent Psychiatry and its industry donors (Arbor & Pfizer) and a research fellowship from The Sorensen Foundation. Dr. Perez receives royalties from Springer for a functional movement disorder textbook, honoraria for continuing medical education lectures on functional neurological disorder, is a paid associate editor of Brain and Behavior, and receives funding from the National Institutes of Health and Sidney R. Baer Jr. Foundation unrelated to this work. Dr. Rosendale receives research funding from the American Academy of Neurology and National Institutes of Health StrokeNet Fellowship. She receives royalties from McGraw Hill for authorship of a chapter in Current Medical Diagnosis and Treatment 2022 and 2023., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Functional neurologic disorder (FND) is a common condition for which neurology residents often receive little to no formal teaching. Using a question-and-answer format, this article puts forward a case for why an FND curriculum is needed and aims to provide guidance on possible curricular content including medical knowledge, clinical skills, communication, and team-based collaboration. The authors also discuss methods for teaching and evaluating this knowledge and associated clinical skills, linking this to current Accreditation Council for Graduate Medical Education neurology milestones. Finally, the authors consider how to better engage and energize neurology trainees around this underserved yet challenging patient population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: While expert consensus recommendations support the use of speech and language therapy (SLT) for patients with functional speech disorder (FND-speech), there are limited published data on clinical outcomes., Objective: To retrospectively report the treatment outcomes and clinical characteristics of patients with FND-speech that attended outpatient SLT as part of a multidisciplinary program for functional neurological disorder (FND)., Methods: In this case series, we included adult patients with FND-speech that consecutively participated in outpatient SLT at our institution between October 2014 and September 2021. Baseline demographic and neuropsychiatric characteristics were extracted from the medical records, along with data on FND-speech phenotypes, number of treatment sessions received, and clinician-determined outcomes. Only descriptive statistics were used to report findings., Results: Twenty patients met inclusion criteria; ages ranged from 21-77, with a mean of 51.6±16.2 years. 85% of the cohort presented with mixed FND-speech symptoms. Patients attended a range of 2-37 visits, with an average of 9.2±8.0 visits over 4.4±3.5 months. At the last treatment session, 3 patients were asymptomatic, 15 had improved, and 2 had not improved; 8 individuals that improved received video telehealth interventions., Conclusion: This case series lends additional support for outpatient SLT in the assessment and management of individuals with FND-speech, and may help clarify patient and provider treatment expectations. Additional prospective research is needed to investigate baseline predictors of treatment response and further define the optimal frequency, intensity, duration, and clinical setting for SLT delivery in this population.

Background and Purpose: Motor functional neurological disorder is a prevalent and costly condition at the intersection of neurology and psychiatry that is diagnosed using positive "rule-in" signs. Physical therapy is a first-line treatment and consensus recommendations exist to guide clinical care. Nonetheless, optimal outpatient treatment of adults with functional motor symptoms requires an expanded physical therapy tool kit to effectively guide care., Summary of Key Points: In this article, lessons learned from a physical therapist practicing in a multidisciplinary and interdisciplinary outpatient functional neurological disorder clinic are highlighted. In doing so, we discuss how use of the biopsychosocial model and neuroscience constructs can inform physical therapy interventions. The importance of team-based care and the delivery of physical therapy through video telehealth services are also outlined., Recommendations for Clinical Practice: Use of the biopsychosocial formulation to triage clinical challenges and guide longitudinal care, coupled with application of neuroscience to aid intervention selection, allows for patient-centered physical therapy treatment across the spectrum of functional motor symptoms.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A400 )., Competing Interests: David L. Perez and Julie Maggio received funding from the Sidney R. Baer Jr Foundation for participation in this manuscript. Dr Stephen has provided scientific advisory for SwanBio Therapeutics and received research funding from Sanofi-Genzyme for a study of video oculography in late-onset GM2 gangliosidosis. He has received financial support from Sanofi-Genzyme, Biogen, and Biohaven for the conduct of clinical trials. Dr Perez has received honoraria for continuing medical education lectures in functional neurological disorder and royalties from Springer Nature for a functional movement disorder textbook. Julie Maggio has received honoraria for continuing medical education lectures in functional neurological disorder. For the remaining author, no conflicts of interest were declared., (Copyright © 2022 Academy of Neurologic Physical Therapy, APTA.)

Objective: Functional neurological disorder (FND) is a core neuropsychiatric condition. To date, promising yet inconsistently identified neural circuit profiles have been observed in patients with FND, suggesting that gaps remain in our systems-level neurobiological understanding. As such, other important physiological variables, including autonomic, endocrine, and inflammation findings, need to be contextualized for a more complete mechanistic picture., Methods: The investigators conducted a systematic review and meta-analysis of available case-control and cohort studies of FND. PubMed, PsycINFO, and Embase databases were searched for studies from January 1, 1900, to September 1, 2020, that investigated autonomic, endocrine, and inflammation markers in patients with FND. Sixty-six of 2,056 screened records were included in the review, representing 1,699 patients; data from 20 articles were used in the meta-analysis., Results: Findings revealed that children and adolescents with FND, compared with healthy control subjects (HCs), have increased resting heart rate (HR); there is also a tendency toward reduced resting HR variability in patients with FND across the lifespan compared with HCs. In adults, peri-ictal HR differentiated patients with functional seizures from those with epileptic seizures. Other autonomic and endocrine profiles for patients with FND were heterogeneous, with several studies highlighting the importance of individual differences., Conclusions: Inflammation research in FND remains in its early stages. Moving forward, there is a need for the use of larger sample sizes to consider the complex interplay between functional neurological symptoms and behavioral, psychological, autonomic, endocrine, inflammation, neuroimaging, and epigenetic/genetic data. More research is also needed to determine whether FND is mechanistically (and etiologically) similar or distinct across phenotypes.

Background: As a group, individuals with functional neurological disorder (FND) report an approximately 3-fold increase in adverse life experiences (ALEs) compared to healthy controls. In patients with FND, studies have identified a positive correlation between symptom severity and the magnitude of ALEs. While not all individuals with FND report ALEs, such findings raise the possibility of a trauma-subtype of FND., Objective: This study investigated if patients with FND, with or without probable post-traumatic stress disorder (PTSD) and/or significant childhood maltreatment, differed in their symptom severity and physical health., Materials and Methods: Seventy-eight patients with FND were recruited (functional seizures, n = 34; functional movement disorder, n = 56). Participants completed self-report measures of symptom severity [Somatoform Dissociation Questionniare-20 (SDQ-20), Screening for Somatoform Disorders: Conversion Disorder subscale (SOMS:CD), Patient Health Questionniare-15 (PHQ-15)], physical health [Short Form Health Survey-36 (SF36-physical health)], childhood maltreatment [Childhood Trauma Questionnaire (CTQ)], and PTSD [PTSD Checklist-5 (PCL-5)]; a psychometric battery of other common predisposing vulnerabilities was also completed. To adjust for multiple comparisons, a Bonferroni correction was applied to all univariate analyses., Results: Patients with FND and probable PTSD ( n = 33) vs. those without probable PTSD ( n = 43) had statistically significant increased scores on all symptom severity measures - as well as decreased physical health scores. In secondary post-hoc regression analyses, these findings remained significant adjusting for age, sex, race, college education, and: pathological dissociation; alexithymia; attachment styles; personality characteristics; resilience scores; functional seizures subtype; or moderate-to-severe childhood abuse and neglect scores; SOMS:CD and SDQ-20 findings also held adjusting for depression and anxiety scores. In a separate set of analyses, patients with FND and moderate-to-severe childhood abuse ( n = 46) vs. those without moderate-to-severe childhood abuse ( n = 32) showed statistically significant increased SDQ-20 and PHQ-15 scores; in post-hoc regressions, these findings held adjusting for demographic and other variables. Stratification by childhood neglect did not relate to symptom severity or physical health scores., Conclusion: This study provides support for a possible trauma-subtype of FND. Future research should investigate the neurobiological and treatment relevance of a FND trauma-subtype, as well as continuing to delineate clinical characteristics and mechanisms in individuals with FND that lack a history of ALEs., Competing Interests: Author DP had received honoraria for continuing medical education lectures on functional neurological disorder, royalties from Springer Nature for a textbook on functional movement disorder, is on the Board of Directors of the Functional Neurological Disorder Society, and on the editorial boards of Epilepsy and Behavior and Brain and Behavior. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Paredes-Echeverri, Guthrie and Perez.)

Within stress-diathesis models, adverse life experiences (ALEs) increase the susceptibility to functional neurological symptoms through neuroplasticity effects. We aimed to characterize potential genetic influences on this relationship in 20 patients with functional seizures. Questionnaires, structural MRIs and Allen Human Brain Atlas gene expression information were used to probe the intersection of symptom severity (Somatoform Dissociation Questionnaire, SDQ-20), ALE burden, and gray matter volumes. SDQ-20 scores positively correlated with sexual trauma, emotional neglect, and threat to life experiences. Higher SDQ-20 scores related to lower bilateral insula, left orbitofrontal, right amygdala, and perigenual/posterior cingulate volumes. Higher sexual trauma burden correlated with lower right posterior insula and putamen volumes; higher emotional neglect related to lower bilateral insula/right amygdala volumes. Findings in left insula/ventral precentral gyrus (SDQ-20), right insula/putamen (sexual trauma), and right amygdala (emotional neglect) held when controlling for comorbid psychopathology. At the intersection of symptom severity and sexual trauma volumetric findings, genes overrepresented in adrenergic, serotonergic, and oxytocin receptor signaling as well as in cortical and amygdala development were spatially correlated. In conclusion, ALEs and symptom severity were associated with gray matter volumes in cingulo-insular and amygdala areas, spatially overlapping with expression patterns of genes involved in stress-related signaling and neurodevelopment., Competing Interests: Declaration of Competing Interest SP receives royalties from Springer for a book on functional neurological disorders; has received speaking fees from Novartis and Esai. D.L.P. has received honoraria for continuing medical education lectures on functional neurological disorder, royalities from Springer Nature for a functional movement disorder textbook and is on the editorial board of Epilepsy & Behavior and Brain and Behavior. The remaining authors have nothing to disclose., (Copyright © 2022. Published by Elsevier B.V.)

Functional neurological disorder reflects impairments in brain networks leading to distressing motor, sensory and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of functional neurological disorder has been the mechanistic and aetiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g. allostasis, predictive processing, interoception and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of functional neurological disorder and related functional somatic symptoms. In doing so, we address several themes for the functional neurological disorder field including: (i) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, 'panic attack without panic', dissociation, insecure attachment and the influential role of life experiences; (ii) re-interpret select neurobiological research findings in functional neurological disorder cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and (iii) discuss therapeutic implications. While we continue to support that functional neurological disorder is mechanistically and aetiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology and cognitive-affective neuroscience., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The etiology of persistent memory complaints after concussion is poorly understood. Memory perfectionism (highly valuing memory ability and intolerance of minor memory lapses) may help explain why some people report persistent subjective memory problems in the absence of corresponding objective memory impairment. This study investigated the relationship between memory perfectionism and persistent memory complaints after concussion., Methods: Secondary analysis of baseline data from a randomized controlled trial. Adults (N = 77; 61% women) with persistent symptoms following concussion were recruited from outpatient specialty clinics. Participants completed the National Institutes of Health Toolbox Cognition Battery, Test of Memory Malingering-Trial 1, and questionnaires measuring memory perfectionism (Metamemory in Adulthood-Achievement subscale), forgetfulness and other postconcussion symptoms (Rivermead Postconcussion Symptoms Questionnaire; RPQ), and depression (Patient Health Questionnaire-2) at M = 17.8 weeks postinjury. Patients with versus without severe memory complaints (based on the RPQ) were compared., Results: Memory perfectionism was associated cross-sectionally with severe memory complaint, after controlling for objective memory ability, overall cognitive ability, and depression (95% confidence interval for odds ratio = 1.11-1.40). Sensitivity analyses showed that this relationship did not depend on use of specific objective memory tests nor on inclusion of participants who failed performance validity testing. In a control comparison to test the specificity of identified relationships, memory perfectionism was not associated with severe fatigue (95% confidence interval for odds ratio = 0.91-1.07)., Conclusions: Memory perfectionism may be a risk factor for persistent memory symptoms after concussion, with potential relevance to the spectrum of functional cognitive disorders more broadly., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: There are gaps in our neurobiological understanding of functional movement disorder (FMD)., Objectives: We investigated gray matter volumetric profiles in FMD, and related findings to resting-state functional connectivity (rsFC) profiles using Human Connectome Project data., Methods: Volumetric differences between 53 FMD patients and 50 controls were examined, as well as relationships between individual differences in FMD symptom severity and volumetric profiles. Atrophy network mapping was also used to probe whether FMD-related structural alterations preferentially impacted brain areas with dense rsFC., Results: Compared to controls without neurological comorbidities (albeit with mild depression and anxiety as a group), the FMD cohort did not show any volumetric differences. Across patients with FMD, individual differences in symptom severity negatively correlated with right supramarginal and bilateral superior temporal gyri volumes. These findings remained significant adjusting for FMD subtype or antidepressant use, but did not remain statistically significant adjusting for depression and anxiety scores. Symptom severity-related structural alterations mapped onto regions with dense rsFC-identifying several disease epicenters in default mode, ventral attention, and salience networks., Conclusions: This study supports that FMD is a multinetwork disorder with an important role for the temporoparietal junction and its related connectivity in the pathophysiology of this condition. More research is needed to explore the intersection of functional neurological symptoms and mood., (© 2022 The Authors. Brain and Behavior published by Wiley Periodicals LLC.)