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

Published online by Cambridge University Press:  30 May 2024

Ryan Van Patten Open the ORCID record for Ryan Van Patten [Opens in a new window] ,
Kristen Mordecai  and
W. Curt LaFrance Jr
Ryan Van Patten*
Affiliation:
Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
Kristen Mordecai
Affiliation:
VA Maryland Health Care System, Baltimore, MD, USA
W. Curt LaFrance Jr
Affiliation:
Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA Rhode Island Hospital, Providence, RI, USA
*
Corresponding author: R. Van Patten; Email: [email protected]
Rights & Permissions [Opens in a new window]

Abstract

Objective:

Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists.

Methods:

A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment.

Results:

Two primary areas of focus for this review are the following: (1) increasing neuropsychologists’ training in FNSDs, and (2) increasing neuropsychologists’ role in assessment and treatment of FNSD patients.

Conclusions:

Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.

Keywords

Functional neurological disorderconversion disorderneuropsychologycognitioneducationintegrated care
Type
Short Review
Information
Journal of the International Neuropsychological Society , Volume 30 , Issue 7 , August 2024 , pp. 710 - 717
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of International Neuropsychological Society

Introduction to functional neurological symptom disorder

Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition presenting with various neurological signs/symptoms and associated with neural network dysfunction rather than focal neuroanatomical lesions (Hallett et al., Reference Hallett, Aybek, Dworetzky, McWhirter, Staab and Stone2022). FNSD is common globally (Kanemoto et al., Reference Kanemoto, LaFrance, Duncan, Gigineishvili, Park, Tadokoro, Ikeda, Paul, Zhou, Taniguchi, Kerr, Oshima, Jin and Reuber2017), on the order of ∼ 100 cases per 100,000 (Asadi-Pooya, Reference Asadi-Pooya2021). It also has a large economic (>$1.2 billion annually; Stephen et al., Reference Stephen, Fung, Lungu and Espay2021) and public health impact, comparable to that of well-known neurological conditions such as epilepsy (Asadi-Pooya et al., Reference Asadi-Pooya, Brigo, Tolchin and Valente2021). For example, in functional seizures, > 50% of patients have neuropsychiatric/medical comorbidities (Brown & Reuber, Reference Brown and Reuber2016a; Jennum et al., Reference Jennum, Ibsen and Kjellberg2019), a majority are unemployed and/or on disability (Salinsky et al., Reference Salinsky, Rutecki, Parko, Goy, Storzbach, O’Neil, Binder and Joos2018), and mortality is high (Asadi-Pooya, Reference Asadi-Pooya2021).

FNSD can present with different symptom manifestations, leading to the development of subordinate diagnostic groups that coalesce around the clinical phenotypes. Three of the most common FNSD subtypes with associated cognitive concerns are: functional seizures (FS), functional cognitive disorder (FCD), and functional motor disorder (FMD; Table 1). FS refers to time-limited, paroxysmal motor, sensory, and cognitive alterations that resemble epileptic seizures but lack epileptiform activity (LaFrance et al., Reference LaFrance, Baker, Duncan, Goldstein and Reuber2013); FCD is a cognitive disorder presenting with impairments occurring within a cognitive domain and inconsistently across situations (Ball et al., Reference Ball, McWhirter, Ballard, Bhome, Blackburn, Edwards, Fleming, Fox, Howard, Huntley, Isaacs, Larner, Nicholson, Pennington, Poole, Price, Price, Reuber, Ritchie, Rossor, Schott, Teodoro, Venneri, Stone and Carson2020); and FMD reflects a family of movement abnormalities that are incongruent with respect to classical neurophysiological mechanisms (Perez et al., Reference Perez, Aybek, Popkirov, Kozlowska, Stephen, Anderson, Shura, Ducharme, Carson, Hallett, Nicholson, Stone, LaFrance and Voon2021).

Table 1. Positive clinical features of three common FNDs

A major recent advancement in the identification of FNSD has been an improved understanding that FNSDs can be diagnosed via positive signs, meaning that they are not simply the end result of having ruled out all other possibilities via a plethora of negative medical tests (Espay et al., Reference Espay, Aybek, Carson, Edwards, Goldstein, Hallett, LaFaver, LaFrance, Lang, Nicholson, Nielsen, Reuber, Voon, Stone and Morgante2018). Instead, there are sensitive and specific behavioral and/or physiological features, focusing on neuroanatomic inconsistency and incongruity, which allow for a “rule-in” determination (Table 1). Critically, when made by experienced clinicians, diagnoses of FNSD tend to be accurate and stable across time (Stone et al., Reference Stone, Smyth, Carson, Lewis, Prescott, Warlow and Sharpe2005, Reference Stone, Carson, Duncan, Coleman, Roberts, Warlow, Hibberd, Murray, Cull, Pelosi, Cavanagh, Matthews, Goldbeck, Smyth, Walker, MacMahon and Sharpe2009), with rates of misdiagnosis being similarly low to those of other neurological conditions (Gelauff et al., Reference Gelauff, Carson, Ludwig, Tijssen and Stone2019; Walzl et al., Reference Walzl, Carson and Stone2019).

Cognitive deficits are a core diagnostic criterion in FCD but not in FS/FMD. However, cognitive difficulties are common in all three FNSD subtypes (∼80% of patients with FS/FMD; Butler et al., Reference Butler, Shipston‐Sharman, Seynaeve, Bao, Pick, Bradley‐Westguard and Nicholson2021), and these problems limit treatment gains and reduce quality of life (Jones et al., Reference Jones, Reuber and Norman2016; Věchetová et al., Reference Věchetová, Slovak, Kemlink, Hanzlikova, Dusek, Nikolai, Ruzicka, Edwards and Serranova2018). For example, some evidence suggests that deficits in processing speed are common in FNSDs (Van Patten et al., Reference Van Patten, Austin, Cotton, Chan, Bellone, Mordecai, Altalib, Correia, Twamley, Jones, Sawyer and LaFrancein press) and may be worse in some FNSDs than in other somatic disorders (De Vroege et al., Reference De Vroege, Koppenol, Kop, Riem and Van Der Feltz-Cornelis2021). More generally, impaired selective and divided attention has been proposed as a transdiagnostic feature of all FNSDs, possibly driven by excessive interoceptive monitoring, which attenuates the “attentional reserve” available for pursuing external goals and leads to a diffuse and nonspecific cognitive profile (Teodoro et al., Reference Teodoro, Edwards and Isaacs2018; Willment et al., Reference Willment, Hill, Baslet and Loring2015).

Frameworks

Historical models of FNSD focused primarily or exclusively on psychopathology (particularly trauma) as the etiological underpinning (Zepf, Reference Zepf2015). However, not all patients with FNSD have an abuse history, and although mental health is still known to be a critical factor, contemporary frameworks highlight the interplay of etiological relationships, including between neurobiology, adverse life events, emotional processing, and cognitive control (Brown & Reuber, Reference Brown and Reuber2016b; Hallett et al., Reference Hallett, Aybek, Dworetzky, McWhirter, Staab and Stone2022). For example, abnormalities in connectivity between limbic structures and motor control circuits could be partially responsible for symptom expression in some FNSDs (Baizabal-Carvallo et al., Reference Baizabal-Carvallo, Hallett and Jankovic2019; Maurer et al., Reference Maurer, LaFaver, Limachia, Capitan, Ameli, Sinclair, Epstein, Hallett and Horovitz2018), while dysfunctional fronto/parietal emotion processing may be related to frequent psychopathology and cognitive symptoms (Pick et al., Reference Pick, Goldstein, Perez and Nicholson2019; Teodoro et al., Reference Teodoro, Edwards and Isaacs2018).

Supplementing advancements in neural associations, the nosology of FNSD has also changed across time. For example, there is some debate about the degree to which FNSD should be primarily conceptualized as a unitary construct versus centering on individual subtypes. On one hand, there is accumulating evidence for shared pathophysiology and underlying cognitive deficits across FS, FCD, and FMD (Hallett et al., Reference Hallett, Aybek, Dworetzky, McWhirter, Staab and Stone2022; Teodoro et al., Reference Teodoro, Edwards and Isaacs2018), arguing for a so-called “lumping” approach. On the other hand, there is mixed evidence with respect to individual phenotypes, with some data suggesting transdiagnostic presentations (Finkelstein & Popkirov, Reference Finkelstein and Popkirov2023; Forejtová et al., Reference Forejtová, Serranová, Sieger, Slovák, Nováková, Věchetová, Růžička and Edwards2023), and other literature highlighting unique symptom expressions (Kola & LaFaver, Reference Kola and LaFaver2022; Matin et al., Reference Matin, Young, Williams, LaFrance, King, Caplan, Chemali, Weilburg, Dickerson and Perez2017), possibly supporting “splitting.” Currently, many researchers strike a balance, with some attention spent on overlapping characteristics of all FNSD (e.g., functional connectivity abnormalities; Drane et al., Reference Drane, Fani, Hallett, Khalsa, Perez and Roberts2021; Pick et al., Reference Pick, Goldstein, Perez and Nicholson2019) and additional complementary investigations highlighting nonshared symptoms and treatment approaches (e.g., response to interventions; Goldstein et al., Reference Goldstein, Robinson, Mellers, Stone, Carson, Reuber, Medford, McCrone, Murray, Richardson, Pilecka, Eastwood, Moore, Mosweu, Perdue, Landau, Chalder, Abe, Adab and Yogarajah2020; Poole et al., Reference Poole, Cope, Vanzan, Duffus, Mantovani, Smith, Barrett, Tokley, Scicluna, Beardmore, Turner, Edwards and Howard2023).

From a clinical standpoint, an important framework that informs the biopsychosocial formulation (Mack & LaFrance, Reference Mack, LaFrance, LaFaver, Maurer, Perez and Nicholson2022) is that of predisposing, precipitating, and perpetuating factors for FNSD (LaFrance & Devinsky, Reference LaFrance and Devinsky2002). Predisposing factors are longstanding risk factors that increase a person’s overall vulnerability to FNSD, precipitating factors are acute/subacute events that represent a “final straw” in the initial presentation of an FNSD, and perpetuating factors are ongoing stressors or experiences that serve as barriers to healing and recovery (Ertan et al., Reference Ertan, Aybek, LaFrance, Kanemoto, Tarrada, Maillard, El-Hage and Hingray2022). For example, predisposing factors for FNSDs could include childhood adversity or chronic illness, precipitating factors could be a closed head injury or a reaction to a vaccine, and perpetuating factors may be medical/social stigma or protracted litigation (Chen & LaFrance, Reference Chen, LaFrance and Mula2021; Fung et al., Reference Fung, Sa’di, Katzberg, Chen, Lang, Cheung and Fasano2023). Within this model, clinicians can identify variables that guide decisions related to neuropsychological assessment (e.g., interview questions, test selection), case conceptualization (e.g., etiology, contributing factors), and treatment (e.g., psychoeducation, treatment planning). In terms of case conceptualization, neuropsychologists and other clinicians can use this biopsychosocial information to generate hypothesized explanations for patients’ persistent cognitive symptoms based on the fear avoidance model, which has been applied to FNSDs (LaFrance & Bjonaes, Reference LaFrance, Bjonaes, LaFrance and Schachter2018). The model helps explain perpetuating factors for treatment-resistant cognitive symptoms with a focus on negative expectations and catastrophizing in some patients (e.g., believing that a mild TBI will cause severe brain damage; Wijenberg et al., Reference Wijenberg, Hicks, Downing, Van Heugten, Stapert and Ponsford2020), which can lead to anxiety/worry, avoidance of cognitively-taxing tasks (e.g., work/school), and a corresponding reduction in functional independence. Ultimately, using the biopsychosocial framework to identify and discuss an individualized formulation with a patient and their family is the current gold standard of care in FNSD, particularly in the setting of an interdisciplinary team, where a neuropsychologist can lean upon their relevant foundational skills (Table 2) to offer clinical insights into case conceptualization and treatment planning (Gilmour et al., Reference Gilmour, Nielsen, Teodoro, Yogarajah, Coebergh, Dilley, Martino and Edwards2020; Keatley & Molton, Reference Keatley and Molton2022; Silverberg & Rush, Reference Silverberg and Rush2023).

Table 2. Alignment of FNSD characteristics with neuropsychologists’ knowledge and skills

Management and treatment

Iatrogenesis

FNSD is difficult to treat due to persistent/disabling symptoms (Ducroizet et al., Reference Ducroizet, Zimianti, Golder, Hearne, Edwards, Nielsen and Coebergh2023; Durrant et al., Reference Durrant, Rickards and Cavanna2011; Gelauff et al., Reference Gelauff, Stone, Edwards and Carson2014, Reference Gelauff, Carson, Ludwig, Tijssen and Stone2019), as well as frequent neuromedical and psychiatric comorbidities (Carle-Toulemonde et al., Reference Carle-Toulemonde, Goutte, Do-Quang-Cantagrel, Mouchabac, Joly and Garcin2023; Jennum et al., Reference Jennum, Ibsen and Kjellberg2019). Although poor outcomes in patients with FNSD are partially attributable to inherent symptom severity/heterogeneity, clinicians have also erred (Burke, Reference Burke2019), as there have been significant problems arising from underrecognition and frequent misunderstandings about FNSD (Keynejad et al., Reference Keynejad, Carson, David and Nicholson2017; Klinke et al., Reference Klinke, Hjartardóttir, Hauksdóttir, Jónsdóttir, Hjaltason and Andrésdóttir2021; McWhirter et al., Reference McWhirter, Ritchie, Stone and Carson2022). That is, confusion stemming from “organic versus non-organic” distinctions (Stone & Carson, Reference Stone and Carson2017), dichotomizing mind/brain conceptualizations (Rawlings & Reuber, Reference Rawlings and Reuber2018), and judgment/stigma about “medically unexplained illnesses” (Foley et al., Reference Foley, Kirkby and Eccles2022), has led to a great deal of avoidance and “passing the buck” occurring amongst clinicians (Barnett et al., Reference Barnett, Davis, Mitchell and Tyson2022; Ducroizet et al., Reference Ducroizet, Zimianti, Golder, Hearne, Edwards, Nielsen and Coebergh2023).

In one example of a common misconception, surveys of neurologists and psychiatrists have documented beliefs that FNSD is indistinguishable from factitious disorder or malingering (Dent et al., Reference Dent, Stanton and Kanaan2020; Kanaan et al., Reference Kanaan, Armstrong and Wessely2011) in spite of a wealth of evidence to the contrary (Edwards et al., Reference Edwards, Yogarajah and Stone2023; McWhirter et al., Reference McWhirter, Ritchie, Stone and Carson2020). This literature shows that, when a patient with an FNSD has a neurological symptom such as limb weakness or memory loss, the symptom is not purposefully feigned in order to achieve secondary gain and/or attention. Instead, there are impairments in interoception and a sense of agency in people with FNSDs (Drane et al., Reference Drane, Fani, Hallett, Khalsa, Perez and Roberts2021; Pick et al., Reference Pick, Goldstein, Perez and Nicholson2019), with a complex pathophysiology that leads to a decrement in the volitional control over sensorimotor experiences and that may contribute to FNSD symptom expression (Hallett et al., Reference Hallett, Aybek, Dworetzky, McWhirter, Staab and Stone2022). Nevertheless, the persistent idea that these patients are faking symptoms is associated with skepticism, frustration, deprioritization, and even discrimination amongst some clinicians, which can lead to iatrogenesis (Foley et al., Reference Foley, Kirkby and Eccles2022; Rawlings & Reuber, Reference Rawlings and Reuber2018). This risk for negative outcomes associated with misdiagnosis of FNSDs as factitious disorder or malingering makes the judicious use and careful interpretation of symptom and performance validity tests by neuropsychologists a particularly important clinical function (Table 2; Edwards et al., Reference Edwards, Yogarajah and Stone2023; Silverberg & Rush, Reference Silverberg and Rush2023).

Advancements in management and treatment

Multiple efforts have been made to improve outcomes for patients with FNSDs, including (1) enhancements to medical education (Barnett et al., Reference Barnett, Davis, Mitchell and Tyson2022; Rawlings & Reuber, Reference Rawlings and Reuber2018), (2) guidelines for communication with patients (Finkelstein et al., Reference Finkelstein, Adams, Tuttle, Saxena and Perez2022; Rockliffe-Fidler & Willis, Reference Rockliffe-Fidler and Willis2019), (3) the development of evidence-based psychotherapeutic interventions (Goldstein et al., Reference Goldstein, Robinson, Mellers, Stone, Carson, Reuber, Medford, McCrone, Murray, Richardson, Pilecka, Eastwood, Moore, Mosweu, Perdue, Landau, Chalder, Abe, Adab and Yogarajah2020; LaFrance et al., Reference LaFrance, Barry, Blum, Webb, Keitner, Machan, Miller and Szaflarski2014), and (4) increased interdisciplinary care (Lidstone et al., Reference Lidstone, MacGillivray and Lang2020; Petrie et al., Reference Petrie, Lehn, Barratt, Hughes, Roberts, Fitzhenry and Gane2023). Items 1 and 4 are expanded upon below because of their relevance to neuropsychologists. Regarding education, it has become well recognized that many clinicians lack sufficient instruction in FNSD, leading to the knowledge gaps mentioned above (Klinke et al., Reference Klinke, Hjartardóttir, Hauksdóttir, Jónsdóttir, Hjaltason and Andrésdóttir2021; Rawlings & Reuber, Reference Rawlings and Reuber2018). In response, several groups have constructed FNSD-specific teaching initiatives. First, the Functional Neurological Disorder Society (website) Education Committee has produced a wide variety of interdisciplinary training resources, including content in the form of freestanding webinars, podcast episodes, and an on-demand virtual education course available for continuing education credits. Second, Medina and colleagues (2021) piloted a series of six 60-minute workshops for psychiatry trainees and reported improved knowledge of and comfort with FNSD, including increased confidence in discussing diagnosis and treatment with patients, as well as consensus beliefs that FNSD symptoms are “real” (not faked or malingered). Third, providers from the U.S. Veterans Administration created the Mind Brain Program (website) to equip clinicians in managing neuropsychiatric disorders. In this program, organization providers utilize online educational platforms and 1-on-1 distance supervision for training clinic programs, which is increasing nationwide access to evidence-based therapy (LaFrance & Clark, Reference LaFrance, Clark, Bajestan, Baslet and Carlson2024).

Efforts to promote interdisciplinary care seek to address the multifaceted nature of FNSD within a biopsychosocial framework that reduces stigma and individualizes the treatment approach (Aybek & Perez, Reference Aybek and Perez2022; Gilmour et al., Reference Gilmour, Nielsen, Teodoro, Yogarajah, Coebergh, Dilley, Martino and Edwards2020). This movement can be distinguished from a “siloed” model of care, where a patient presents first to a neurologist and then is sent to an outside mental health clinician, without either professional collaborating with the other or assuming responsibility. In contrast, in an integrated model, the patient initially undergoes a thorough neuropsychiatric assessment, which is then translated into a personalized intervention provided by a collaborative team, addressing physical/neurological (Nielsen et al., Reference Nielsen, Stone, Matthews, Brown, Sparkes, Farmer, Masterton, Duncan, Winters, Daniell, Lumsden, Carson, David and Edwards2015), mental health (Oriuwa et al., Reference Oriuwa, Mollica, Feinstein, Giacobbe, Lipsman, Perez and Burke2022), and social/situational (LaFaver et al., Reference LaFaver, LaFrance, Price, Rosen and Rapaport2021) concerns. To date, positive results have been found with integrated interventions (Jacob et al., Reference Jacob, Smith, Jablonski, Roach, Paper, Kaelin, Stretz-Thurmond and LaFaver2018; Jimenez et al., Reference Jimenez, Aboussouan and Johnson2019; Lidstone et al., Reference Lidstone, MacGillivray and Lang2020), although the role of neuropsychology has been largely neglected, in spite of the prominence of cognitive dysfunction across FNSD subtypes (Carle-Toulemonde et al., Reference Carle-Toulemonde, Goutte, Do-Quang-Cantagrel, Mouchabac, Joly and Garcin2023; Jones et al., Reference Jones, Reuber and Norman2016; Teodoro et al., Reference Teodoro, Edwards and Isaacs2018). That is, neuropsychologists can contribute to an interdisciplinary FNSD team with a thorough biopsychosocial clinical formulation, cognitive assessment to characterize strengths and weaknesses, and cognitive rehabilitation targeting the most distressing and disabling symptoms.

Regarding options for cognitive rehabilitation, as yet there are no formal evidence-based treatments specifically targeting FNSDs. However, broad-based compensatory approaches have been successfully used in other related disorders (e.g., psychosis, TBI, stroke; Twamley et al., Reference Twamley, Vella, Burton, Heaton and Jeste2012, Reference Twamley, Thomas, Gregory, Jak, Bondi, Delis and Lohr2015; Winkens et al., Reference Winkens, Van Heugten, Wade, Habets and Fasotti2009) and are available to clinicians. Until an FNSD-specific protocol is published, neuropsychologists can adapt these general techniques for use in patients with FNSDs in individual clinical scenarios. For example, several case studies have successfully applied compensatory techniques in FNSDs, including an example of general cognitive rehabilitation combined with psychotherapy that was associated with improvements on memory test scores (Laatsch & Taber, Reference Laatsch and Taber1997) and an application of techniques to address processing speed, which improved mental slowness and other cognitive symptoms (De Vroege et al., Reference De Vroege, Khasho, Foruz and Van Der Feltz-Cornelis2017).

FNSD in neuropsychology

As the movement toward interdisciplinary FNSD care has gained momentum (Lopez et al., Reference Lopez, Mordecai, Blanken and LaFrance2023), a variety of allied healthcare specialties have joined neurologists and psychiatrists as active members of treatment teams. This is reflected in published consensus statements in occupational therapy (Nicholson et al., Reference Nicholson, Edwards, Carson, Gardiner, Golder, Hayward, Humblestone, Jinadu, Lumsden, MacLean, Main, Macgregor, Nielsen, Oakley, Price, Ranford, Ranu, Sum and Stone2020), physical therapy (Nielsen et al., Reference Nielsen, Stone, Matthews, Brown, Sparkes, Farmer, Masterton, Duncan, Winters, Daniell, Lumsden, Carson, David and Edwards2015), speech language pathology (Baker et al., Reference Baker, Barnett, Cavalli, Dietrich, Dixon, Duffy, Elias, Fraser, Freeburn, Gregory, McKenzie, Miller, Patterson, Roth, Roy, Short, Utianski, van Mersbergen, Vertigan, Carson, Stone and McWhirter2021), and general health service psychology (Keatley & Molton, Reference Keatley and Molton2022). By contrast, the role of neuropsychology is typically not detailed in discussions of interdisciplinary FNSD care, in spite of the fact that neuropsychologists possess a relevant knowledge base and skillset that would allow for unique insights in many clinical situations (see Table 2).

In order to expand the role of neuropsychologists in the care of patients with FNSD, it is first necessary to: (1) enhance FNSD-specific education in neuropsychology training programs, and (2) advocate for appropriate patient referrals and inclusion of neuropsychologists in interdisciplinary teams. Regarding the former, similar to physicians, many neuropsychologists do not receive consistent/robust instruction on various FNSD presentations (including FCD; Silverberg & Rush, Reference Silverberg and Rush2023), likely leading to knowledge gaps and clinical uncertainty. Importantly, the field of neuropsychology is ripe for the incorporation of more comprehensive content coverage of FNSDs due to significant ongoing development and innovation in current training models. The changes primarily revolve around the revision of the Houston Conference Guidelines (Hannay et al., Reference Hannay, Bieliauskas, Crosson, Hammeke, Hamsher and Koffler1998), which is instantiated in the Minnesota Update Conference (MNC). One overarching goal of the MNC is to delineate entry level competencies for practicing neuropsychology, linked to strategies for implementation within existing training programs. Similar to that of other highly prevalent disorders with major public health impacts, FNSD education should be integrated across neuropsychology training in the form of coursework, didactics, clinical vignettes, discussions of scientific literature, and other activities (Table 3). And as more neuropsychologists become knowledgeable about and skilled in FNSD-specific issues through educational efforts, it is incumbent upon these professionals to advocate for a role in the care of patients with FNSD (Table 4).

Table 3. Recommendations for FNSD-specific education in neuropsychology training programs

* Two example publications are provided for FNSDs and for each of the three subtypes. These examples are not exhaustive and the reader may wish to select many additional papers from the current bibliography in order to begin building a local repository of scientific work in FNSDs.

† Many resources provided are online/digital methods of education. There is growing interest in webinars and podcasts as formal didactic tools to assist in the achievement of competencies in neuropsychology (Van Patten et al., Reference Van Patten, Bellone, Schmitt, Gaynor and Block2022).

Table 4. Specific functions of neuropsychologists in the care of patients with functional neurological symptom disorder

Conclusions

FNSD is prevalent and impactful but has been underrecognized in all healthcare specialties, including neuropsychology. Recent years have seen significant advancements in the FNSD literature that can improve healthcare provision and outcomes for these patients. Multiple specialties have proposed educational programs and guidelines/recommendations for their profession’s role in integrated treatment for FNSD patients. Neuropsychologists have strong foundational brain-behavior skills that would allow for positive contributions to FNSD patient care. To facilitate this progress, the current review provides actionable recommendations for incorporating FNSD education into neuropsychology training and for further integrating neuropsychologists into current clinical care models.

Funding statement

R. Van Patten receives funding from VA Providence, RR&D Center for Neurorestoration and Neurotechnology. He engages in profit sharing with the International Neuropsychological Society for Continuing Education proceeds from the Navigating Neuropsychology podcast. He also receives royalties from publication of the book, Becoming a Neuropsychologist: Advice and Guidance for Students and Trainees (Springer, 2021). The research reported/outlined here was supported by the Department of Veterans Affairs, Veterans Health Administration, VISN 1 Career Development Award to Ryan Van Patten.

K. Mordecai has no financial disclosures.

W.C. LaFrance, Jr. receives editor’s royalties from the publication of Gates and Rowan’s Nonepileptic Seizures, 3rd ed. (Cambridge University Press, 2010) and 4th ed. (2018); author’s royalties for Taking Control of Your Seizures: Workbook and Therapist Guide (Oxford University Press, 2015); has received research support from the Department of Defense (DoD W81XWH-17-0169), NIH (NINDS 5K23NS45902) [PI], VA Providence HCS, Center for Neurorestoration and Neurorehabilitation, Rhode Island Hospital, the American Epilepsy Society (AES), the Epilepsy Foundation, Brown University and the Siravo Foundation; has served on the Epilepsy Foundation New England Professional Advisory Board, the Functional Neurological Disorder Society Board of Directors, the American Neuropsychiatric Association Advisory Council; has received honoraria for the American Academy of Neurology, AES and Behavioral Aspects of Neurology Annual Meetings.

Competing interests

R. Van Patten has served on the editorial boards of Archives of Clinical Neuropsychology, International Psychogeriatrics, Journal of Clinical and Experimental Neuropsychology, Frontiers in Neurology, and Frontiers in Psychology.

K. Mordecai has no competing interests.

W.C. LaFrance, Jr. has served on the editorial boards of Epilepsia, Epilepsy & Behavior; Journal of Neurology, Neurosurgery and Psychiatry, and Journal of Neuropsychiatry and Clinical Neurosciences; has served as a clinic development consultant at University of Colorado Denver, Cleveland Clinic, Spectrum Health, Emory University, Oregon Health Sciences University and Vanderbilt University; and has provided medico legal expert testimony.

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Figure 0

Table 1. Positive clinical features of three common FNDs

Figure 1

Table 2. Alignment of FNSD characteristics with neuropsychologists’ knowledge and skills

Figure 2

Table 3. Recommendations for FNSD-specific education in neuropsychology training programs

Figure 3

Table 4. Specific functions of neuropsychologists in the care of patients with functional neurological symptom disorder