Functional cognitive disorder: dementia's blind spot

Harriet A Ball*, Laura McWhirter, Clive Ballard, Rohan Bhome, Dan Blackburn, Mark Edwards, Stephe Fleming, Nick Fox, Robert Howard, Jonathan Huntley, Jeremy Isaacs, AJ Larner, Timothy Nicholson, Catherine M Pennington, Norman Poole, Gary Price, jason Price, Markus Reuber, Craig Ritchie, Martin RossorJonathan Schott, Tiago Teodoro, Annalena Venneri, Jonathan Stone, Alan J Carson

*Corresponding author for this work

Research output: Contribution to journalReview article (Academic Journal)peer-review

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Abstract

An increasing proportion of cognitive difficulties are recognised to have a functional cause, the chief clinical indicator of which is internal inconsistency. When these symptoms are impairing or distressing, and not better explained by other disorders, this can be conceptualised as a cognitive variant of Functional Neurological Disorder (FND), termed Functional Cognitive Disorder (FCD). FCD is likely very common in clinical practice but may be under-diagnosed. Clinicians in many settings make liberal use of the descriptive term Mild Cognitive Impairment (MCI) for those with cognitive difficulties not impairing enough to qualify as dementia. However, MCI is an aetiology-neutral description, which therefore includes patients with a wide range of underlying causes. Consequently, a proportion of MCI cases are due to non-neurodegenerative processes, including FCD. Indeed, significant numbers of patients diagnosed with MCI do not "convert" to dementia. The lack of diagnostic specificity for MCI "non-progressors" is a weakness inherent in framing MCI primarily within a deterministic neurodegenerative pathway. It is recognised that depression, anxiety and behavioural changes can represent a prodrome to neurodegeneration; empirical data are required to explore whether the same might hold for subsets of people with FCD. Clinicians and researchers can improve study efficacy and patient outcomes by viewing MCI as a descriptive term with a wide differential diagnosis, including potentially reversible components such as FCD. We present a preliminary definition of Functional Neurological Disorder- Cognitive Subtype, explain its position in relation to other cognitive diagnoses and emerging biomarkers, highlight clinical features that can lead to positive diagnosis (as opposed to a diagnosis of exclusion), and red flags that should prompt consideration of alternative diagnoses. In the research setting, positive identifiers of FCD will enhance our recognition of individuals who are not in a neurodegenerative prodrome, while greater use of this diagnosis in clinical practice will facilitate personalised interventions.
Original languageEnglish
Article numberawaa224
Number of pages9
JournalBrain
DOIs
Publication statusPublished - 13 Aug 2020

Keywords

  • cognition
  • dementia
  • functional cognitive disorder
  • functional neurological disorder
  • mild cognitive impairment

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