Functional cognitive disorders: clinical presentations and treatment approaches

Abstract

Functional cognitive disorders (FCDs) are a common cause of subjective and mild cognitive impairment. Isolated FCDs commonly present to the cognitive clinic, but examination of the nature of the symptoms suggests that they can also be understood as a transdiagnostic feature of many other conditions. This article examines methods of formulating the cognitive difficulties in order to identify treatment targets in people with FCDs.

A Case of Functional Cognitive Disorder: Psychotherapy and Speech and Language Therapy Insights

“…Declining to attempt certain tasks, distress with testing, and inconsistent performance within a single domain (the latter being the most salient point) all suggested a diagnosis of FCD. 15 Treatment was initiated using a patient-centered, goalbased rehabilitation approach. This combined contextualized metacognitive strategy training is common in SLT practice for acquired neurologic disorders.…”

“…24 There is also increasing interest in understanding how FCD may intersect with persistent symptoms after mild TBI, other functional somatic syndromes (e.g., fibromyalgia), and chronic/long COVID-19. 15,25,26 While Ms. C's case provides a strong example of the utility of an FCD diagnosis, more research is needed to define the boundaries between FCD and other medical and neuropsychiatric causes of cognitive difficulties. A particularly common scenario in memory and behavioral neurology/ neuropsychiatry clinics is encountering middle-aged individuals with subthreshold or underdiagnosed generalized anxiety disorder and/or dysthymia.…”

“…FCD is primarily conceptualized in a cognitive-behavioral model. 25,15 In this model, there are two primary types of psychological mechanisms perpetuating the disorder, maladaptive thoughts and coping behaviors. Maladaptive thoughts arise in anticipation of cognitive difficulties ("I won't be able to remember that") or in response to a cognitive lapse ("Something is definitely wrong with my brain") as the result of characteristic biases.…”

“…Preoccupation with worry about brain health can be distracting, resulting in absentminded errors. 15 Anticipatory anxiety is associated with sympathetic nervous symptom arousal beyond the inflexion point on the Yerkes-Dodson curve, impeding cognitive performance. It may also motivate top-down control when automated performance is optimal (e.g., word finding).…”

“…37 Addressing overuse of memory compensatory aids is recognized as a goal in FCD clinical management. 15,38 There is an argument, however, for temporarily allowing or even introducing compensatory strategies if it enables a patient to increase their independence or enter the preliminary stage of a graded exposure hierarchy (ladder). For example, Ms. C did not use her stove.…”