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Purpose: Little is known about the accuracy of the GAD-7, a self-report anxiety measure, in detecting generalised anxiety disorder (GAD) in people with dissociative seizures (DS). We evaluated the reliability, validity and uniformity of the GAD-7 using a diagnosis of GAD on the Mini-International Neuropsychiatric Interview as a reference. Methods: We assessed 368 adults with DS at the pre-randomisation phase of the CODES trial. Factor analysis for categorical data assessed GAD-7 uniformity. Diagnostic accuracy was assessed by estimating the area under the curve (AUC). We evaluated discriminant validity, reviewed data on convergent validity and calculated internal consistency. We explored correlations between GAD-7 scores and monthly DS frequency, frequency of severe seizures and measures of behavioural and emotional avoidance. Results: Internal consistency of the GAD-7 was high (α = 0.92). Factor analysis elicited one main factor and general measurement invariance. Diagnostic accuracy was fair (AUC = 0.72) but the best balance of sensitivity and specificity occurred at a cut-off of ≥12 and still had a specificity rate of only 68%. Discriminant and convergent validity were good. GAD-7 scores correlated positively with DS frequency, severe seizure frequency, behavioural and emotional avoidance (all p < 0.001). Conclusion: Findings regarding internal consistency and factor structure parallel previous psychometric evaluations of the GAD-7. Correlations between GAD-7 scores and DS occurrence/severity and avoidance are evidence of the concept validity of GAD-7 and provide further support for a fear-avoidance treatment model for DS. However, the utility of the GAD-7 as a diagnostic instrument for generalised anxiety disorder is limited in patients with DS.

BACKGROUND: Chronic pain is a common comorbidity in those with functional neurological disorder (FND), however the prevalence and characteristics of FND in those with chronic pain is unknown.METHODS: A retrospective electronic records review of consecutive new patients attending a chronic pain clinic of a regional service. Clinical features, medication and outcome of chronic pain, any lifetime diagnoses of functional, FND and psychiatric disorders and undiagnosed neurological symptoms were recorded.RESULTS: Of 190 patients attending the chronic pain clinic, 32 (17%) had a lifetime diagnosis of FND and an additional 11 (6%) had undiagnosed neurological symptoms. Pain patients with comorbid FND were more likely to have chronic primary pain (88% with FND, 44% without FND, p CONCLUSIONS: This first study of FND in a chronic pain patient population found a remarkably high prevalence of FND (17%) and is possibly an underestimate. The size of the overlap indicates that FND and chronic pain research fields are likely to have a lot to learn from each other.

BackgroundThe literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed.MethodsWe systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsWe identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed.ConclusionsAfter acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.

Background and purpose Functional neurological disorder (FND) is common, and symptoms can be severe. There have been no international large-scale studies of patient experiences of FND. Methods A patient questionnaire was created to assess FND patient characteristics, symptom comorbidities and illness perceptions. Respondents were recruited internationally through an open access questionnaire via social media and patient groups over a month-long period. Results In total, 1048 respondents from 16 countries participated. Mean age was 42 years (86% female). Median FND symptom duration was 5 years, and median time from first symptom to diagnosis was 2 years. Mean number of current symptoms (core FND and associated) was 9.9. Many respondents had associated symptoms, for example fatigue (93%), memory difficulties (80%) and headache (70%). Self-reported psychiatric comorbidities were relatively common (depression, 43%; anxiety, 51%; panic, 20%; and post-traumatic stress disorder, 22%). Most respondents reported that FND had multiple causes, including physical and psychological. Conclusions This large survey adds further evidence that people with FND typically have high levels of multiple symptom comorbidity with resultant distress. It also supports the notion that associated physical symptoms are of particular clinical significance in FND patients. Dualistic ideas of FND were not supported by respondents, who generally preferred to conceptualize the disorder as one at the interface of mind and brain. The need for a broad approach to this poorly served patient group is highlighted. Potential selection and response biases due to distribution of the survey online, mostly via FND patient groups, are a key limitation.

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

ObjectiveTo describe clinical features relevant to diagnosis, mechanism, and etiology in patients with “scan-negative” cauda equina syndrome (CES).MethodsWe carried out a prospective study of consecutive patients presenting with the clinical features of CES to a regional neurosurgery center comprising semi-structured interview and questionnaires investigating presenting symptoms, neurologic examination, psychiatric and functional disorder comorbidity, bladder/bowel/sexual function, distress, and disability.ResultsA total of 198 patients presented consecutively over 28 months. A total of 47 were diagnosed with scan-positive CES (mean age 48 years, 43% female). A total of 76 mixed category patients had nerve root compression/displacement without CES compression (mean age 46 years, 71% female) and 61 patients had scan-negative CES (mean age 40 years, 77% female). An alternative neurologic cause of CES emerged in 14/198 patients during admission and 4/151 patients with mean duration 25 months follow-up. Patients with scan-negative CES had more positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative,p< 0.0001), were more likely to describe their current back pain as worst ever (41% vs 46% and 70%,p= 0.005), and were more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%,p= 0.001). Patients with scan-positive CES were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%,p< 0.0001). There was no significant difference between groups in the frequency of reduced anal tone and urinary retention.ConclusionThe first well-phenotyped, prospective study of scan-negative CES supports a model in which acute pain, medication, and mechanisms overlapping with functional neurologic disorders may be relevant.

ObjectiveTo determine whether self-rated health of patients with motor functional neurologic disorder (FND) can be improved by unguided Internet-based self-help and education.MethodsIn this nonblinded randomized controlled trial, patients were allocated 1:1 unbiased to an unguided education and self-help website in addition to usual care or usual care only. Patients over 17 years of age with a functional motor symptom that caused distress or disability were included. The primary outcome was self-rated health on the Clinical Global Improvement scale at 3 and 6 months. Secondary outcomes were severity of motor symptoms, other physical and psychiatric symptoms, physical functioning, quality of life, work and social adjustment, illness beliefs, and satisfaction with care.ResultsA total of 186 patients were randomized, with a follow-up rate of 87% at 6 months. There was no difference in improvement of self-rated health at 3 months (44% vs 40%, p = 0.899) or 6 months (42% vs 43%, p = 0.435). Secondary outcomes did not differ between groups, with a threshold of p < 0.01. Satisfaction was high, with 86% of patients recommending the website to other patients.ConclusionWe found no significant effect of the intervention added to usual care on self-rated health or secondary outcome measures, despite high patient satisfaction with the intervention. These results suggest that online education and nonguided self-help could be valuable additions to stepped care for motor FND, but are not effective treatments as interventions in their own right.Clinicaltrials.gov identifierNCT02589886.Classification of evidenceThis study provides Class III evidence that for patients with motor FND, online education and self-help intervention does not significantly improve self-rated health.

Using archived records, plus oral histories from retired neurologists, Fend et al. examine attitudes to functional neurological disorders in the mid-20th century. While frequently scathing in their correspondence, most neurologists of the time adopted a pragmatic approach with many referring patients to psychiatrists.

PURPOSE: The CODES Trial for adults with dissociative seizures had a predesignated 12-month post-randomisation follow-up point for outcome evaluation. We undertook an exploratory, unplanned, secondary analysis to evaluate the effectiveness of cognitive behavioural therapy plus standardised medical care (CBT+SMC) compared to SMC alone at 6 months post-randomisation, i.e., closer to the end of treatment.METHODS: The analysis of 6-month data followed our previous method of using multiple imputation and an intention-to-treat approach to analyse variables 12 months post-randomisation.RESULTS: The original trial primary outcome of monthly seizure frequency showed greater benefit from CBT+SMC than SMC-alone at 6 months (at p < 0.05). Of 13 comparable previously-defined secondary outcomes, 12 showed a significant between group effect (p < 0.05) in favour of the CBT intervention at 6 months. The average effect size of the comparable previously-defined primary and secondary continuous outcomes was 0.33 at 6 months vs 0.26 at 12 months. The estimated Incidence Rate Ratio (IRR) quantifying monthly seizure reduction was IRR = 0.72 (95%CI from 0.55 to 0.93) at 6 months compared to IRR = 0.78 at 12 months.CONCLUSION: DS-specific CBT (plus SMC) produced evidence of significant benefits at 6 months post- randomisation (around which time CBT was complete) compared to SMC alone; for the majority of these outcomes, better results following CBT (plus SMC) had previously been reported at 12 months. Our pattern of results suggests that short- and longer-term follow-ups are necessary to understand treatment effects in this disorder. Studies only providing short-term follow-up data should be interpreted with caution.

BACKGROUND: To determine gender differences in rates of sexual and physical abuse in functional movement disorders compared to controls and evaluate if the gender disparity of functional movement disorders is associated with abuse history. METHODS: We performed a retrospective case-control study of self-reported trauma data from 696 patients (512 women) with functional movement disorders from six clinical sites compared to 141 controls (98 women) and population data. Chi-square was used to assess gender and disorder associations; logistic regression was used to model additive effects of abuse and calculate the attributable fraction of abuse to disorder prevalence. RESULTS: Higher rates of sexual abuse were reported by women (35.3%) and men (11.5%) with functional movement disorders compared to controls (10.6% of women; 5.6% of men). History of sexual abuse increased the likelihood of functional movement disorders among women by an odds ratio of 4.57 (95% confidence interval, 2.31–9.07; p < 0.0001) and physical abuse by an odds ratio of 2.80 (95% confidence interval, 1.53–5.12; p=0.0007). Population attributable fraction of childhood sexual abuse to functional movement disorders in women was 0.12 (0.05–0.19). No statistically significant associations were found in men, but our cohort of men was underpowered despite including multiple sites. CONCLUSIONS: Our study suggests that violence against women may account for some of the gender disparity in rates of functional movement disorders. Most people with functional movement disorders do not report a history of abuse, so it remains just one among many relevant risk factors to consider.

Functional neurological disorder is common in neurological practice. A new approach to the positive diagnosis of this disorder focuses on recognisable patterns of genuinely experienced symptoms and signs that show variability within the same task and between different tasks over time. Psychological stressors are common risk factors for functional neurological disorder, but are often absent. Four entities-functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder-show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry. All four entities have distinctive features and can be diagnosed with the support of clinical neurophysiological studies and other biomarkers. The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness. Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.

Background and objective People with functional motor disorder (FMD) report triggers—sensory or motor-induced stimuli that exacerbate or initiate paroxysmal occurrences of their movement disorder. These are a distinct phenomenon from precipitating factors occurring at the initial onset of the disorder. We aimed to assess triggers in FMD and understand their relevance to paroxysmal variability often seen in FMD. Methods We enrolled consecutive outpatients with a definite diagnosis of FMD. Each patient underwent a detailed clinical evaluation also including the presence of trigger factors and video-recordings both during neurological examination and physiotherapy treatment. Patients were classified as having “triggers” (T-FMD) or “not having triggers” (NoT-FMD) as well as “paroxysmal” compared to “persistent with paroxysmal variability”. Results The study sample was 100 patients (82% female) with FMD; the mean age at onset was 41 years. Triggers were observed in 88% of patients and in 65 of these the FMD was pure paroxysmal. The most common triggers were movement or physical exercise, followed by emotional, visual, touch, and auditory stimuli; 39 (44%) were isolated and 49 (56%) were combined triggers. Among the T-FMD patients, FMD were paroxysmal in 74% (n = 65) and persistent with paroxysmal variability in 26% (n = 23). The T-FMD patients were younger (p = 0.016) and had a gait disorder (p = 0.035) more frequently than the NoT-FMD patients. Discussion Triggers are frequent in FMD and may have diverse overlapping clinical presentations. In this sample, FMD was most often paroxysmal, suggesting the value of noting triggers as clinical clues in the diagnosis and rehabilitation of FMD.

Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysms of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite this importance, there remains little agreement – and frequent debate – on what to call this condition, known inter alia as psychogenic non-epileptic seizures (PNES), dissociative seizures (DS), functional seizures (FS), non-epileptic attack disorder (NEAD), pseudoseizures, conversion disorder with seizures, and by many other labels besides. This choice of terminology is not merely academic – it affects patients’ response to and understanding of their diagnosis, and their ability to navigate health care systems.This paper summarises two recent discussions hosted by the American Epilepsy Society and Functional Neurological Disorders Society on the naming of this condition. These discussions are conceptualised as the initial step of an exploration of whether it might be possible to build consensus for a new diagnostic label.

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

Objectives/AimsChronic pain is commonly reported as a comorbidity in patients with functional neurological disorder (FND) however the prevalence of FND in those presenting with chronic pain is unknown. We aimed to estimate 1) the prevalence of FND in patients seen at a chronic pain clinic and 2) how patients with chronic pain and comorbid FND differ from those without FND in terms of pain characteristics, psychiatric comorbidity, pain management and pain outcome.MethodsRetrospective electronic records review of consecutive new patients attending chronic pain clinics of 8 pain specialists in Lothian from the 1st of August 2019 to the 19thSeptember of 2019. Mean duration of follow up was 25 months. We recorded the clinical features, medication, management and outcome of chronic pain, any lifetime (up to November 2021) diagnoses of functional, FND and psychiatric disorders and undiagnosed neurological symptoms (where it was unclear if symptoms related to FND or another condition).ResultsOf 190 patients attending a chronic pain clinic, 32 (17%) had at least one lifetime diagnosis of FND and an additional 8 (4%) had undiagnosed neurological symptoms. FND diagnoses were functional limb weakness (8%), functional sensory disorder (8%), dissociative seizures (6%), functional cognitive disorder (5%), functional movement disorder (4%) and others (2%). Chronic primary pain (pConclusionsFND was found in a surprisingly high 17% of new patients at a chronic pain clinic. This may be an underestimate based on an additional 4% of patients with undiagnosed neurological symptoms. Patients with chronic pain and FND are significantly more likely to have chronic primary pain compared to other pain patients but do not experience different pain management or outcome. These results provide further evidence of the important overlap between FND and chronic pain conditions.

ObjectivesEvaluate patients’ and healthcare professionals’ attitudes towards deceptive and open-label placebo treatments, its perceived effectiveness and current use.MethodsA sixteen-item anonymous survey explored attitudes towards deceptive and open-label placebo treatments in clinical practice, its perceived effectiveness and current use. The following groups completed the survey: 288 people with a neurological condition, 138 people with a functional neurological disorder, 61 people with a medical condition, 59 healthy controls and 112 healthcare professionals, of which 45 neurologists and 20 psychiatrists/psychologists.ResultsThe overall attitude to deceptive placebo treatments was favourable amongst non-professionals (69% in favour). The healthcare professionals were more conservative, with only 48% being in favour. However, a considerable number strongly opposed deceptive placebo: 15% of medical patients, 11% of neurological patients and 22% of patients with a functional neurological disorder. Forty-one percent of functional neurological disorder patients, 46% of patients with presumed organic conditions and 70% of healthy controls believed that a deceptive placebo would improve their own symptoms. Healthcare professionals estimated that deceptive placebo treatments would be effective in 31% of purely organic symptoms and in 55% of purely functional symptoms. Major concerns surrounding deceptive placebo involved undermining trust in the medical profession. There was marked scepticism with regards to open-label placebo in all groups, with the general underlying belief that open-label placebo is fairly ineffective.Two-thirds of healthcare professionals had never used deceptive nor open-label placebo. Those who had used it, had done so rarely and mostly for non-specific or functional symptoms or for diagnostic purposes.ConclusionsDespite a generally perceived high effectiveness of deceptive placebo treatments, its prohibition in the UK seems to be in line with general concerns and some strong opposition. Future studies will show if the negative attitude to open-label placebo is justified or if this ethically viable option deserves more consideration.

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

This scientific commentary refers to ‘Reduced drift rate: a biomarker of impaired information processing in functional movement disorders’, by Sadnicka et al. (doi: 10.1093/brain/awz387).

Background: The clinical symptoms and signs of Cauda equina syndrome (CES) are non specific and poorly predictive of cauda equina compression on MRI. We aimed to establish whether a history of lumb...

Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional limb weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional limb weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of limb weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional limb weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional limb weakness group (1%) and in one neurological control (2%). Eleven patients with functional limb weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional limb weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional limb weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional limb weakness. Misdiagnosis in functional limb weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.

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

Highlights • Evidence-based guidelines use systematic reviews to support clinical recommendations. • Adherence to evidence-based guidelines improves healthcare costs and patient outcomes. • Recent randomized trials make guidelines for functional neurological disorders possible., Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.

Highlights • 1st Neuroimaging Workgroup Meeting in Functional Neurological Disorder (FND). • Underscores the importance of FND cohort characterization in brain imaging research. • Details methodological approaches taken in FND neuroimaging research to date. • Research agenda proposed to definitely elucidate the neural circuitry of FND. • Discussions underway regarding having FND researchers join the ENIGMA consortium., Functional neurological disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart – leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed using “rule-in” examination signs. The parallel use of scientific tools to bridge brain structure - function relationships has helped refine an integrated biopsychosocial framework through which to conceptualize FND. In particular, a growing number of quality neuroimaging studies using a variety of methodologies have shed light on the emerging pathophysiology of FND. This renewed scientific interest has occurred in parallel with enhanced interdisciplinary collaborations, as illustrated by new care models combining psychological and physical therapies and the creation of a new multidisciplinary FND society supporting knowledge dissemination in the field. Within this context, this article summarizes the output of the first International FND Neuroimaging Workgroup meeting, held virtually, on June 17th, 2020 to appraise the state of neuroimaging research in the field and to catalyze large-scale collaborations. We first briefly summarize neural circuit models of FND, and then detail the research approaches used to date in FND within core content areas: cohort characterization; control group considerations; task-based functional neuroimaging; resting-state networks; structural neuroimaging; biomarkers of symptom severity and risk of illness; and predictors of treatment response and prognosis. Lastly, we outline a neuroimaging-focused research agenda to elucidate the pathophysiology of FND and aid the development of novel biologically and psychologically-informed treatments.

Patients´ and healthcare professionals´ attitudes to deceptive and open-label placebo treatments in clinical practice were evaluated by means of an anonymous survey.The overall attitude to deceptive placebo treatments was favourable amongst the 310 neurological patients and 100 medical patients/healthy participants taking part in the survey. The 90 healthcare pro- fessionals and 140 patients with a functional neurological disorder were more conservative, with equal numbers being in favour and against.An even more crucial factor is the considerable percentage being strongly opposed to deceptive placebo– 16% of neurological patients and 30% of patients with a functional neurological disorder.The majority of healthcare professionals had never used deceptive placebo, with an even smaller pro- portion ever having used open-label placebo. There was marked scepticism with regards to open-label placebo in all groups, with the general underlying belief that open-label placebo is fairly ineffectiveThe prohibition of deceptive placebo use in the UK seems to be in line with general concerns and oppo- sition to placebo. Future studies will show if the negative attitude to open-label placebo is justified or if this ethically viable option deserves more consideration.The survey is ongoing (to take part, visit https://is.gd/hcp_placebosurvey). The final numbers and conclu- sions may thus change.anne-catherine.huys.15@ucl.ac.uk

BackgroundMore than 50% of patients presenting with cauda equina syndrome (CES) have normal imaging. These patients require phenotyping to ascertain symptom aetiology and mechanism.Prospective Study Results198 patients presented with suspected CES over 28 months. 47 were diagnosed with ‘scan-positive’ CES (mean age 48yrs, 43% female). 76 patients had evidence of nerve root compres- sion or displacement and were placed into a ‘mixed’ category (mean age 46yrs, 71% female) and 61 patients had normal scans ‘scan-negative’ CES (mean age 40yrs, 77% female). Fourteen patients had a neurological diagnosis explaining their clinical CES symptoms during admission.Patients with ‘scan-positive’ CES were more likely to have reduced or lost bilateral ankle jerks (78% vs. 30% and 12%, p≤0.0001). Patients with ‘scan-negative’ CES were found to have positive signs of a functional neurological disorder on examination (11% v. 34% and 68%, p≤0.0001) as well as high rates of panic, medication usage and psychopathology. Four patients out of 151 (4%, mixed group n=3, ‘scan-negative’ group n=1) had a neurological diagnosis after discharged which potentially explained their clinical CES presentation.ConclusionsThis is the first well phenotyped, prospective study of patients with ‘scan-negative’ CES dem- onstrating a pain, medication and functional mechanism of symptom production.ingrid.hoeritzauer@ed.ac.uk

We thank Dr. Amelot et al. for the response to our article.1 We are aware that in other centers only patients with positive scans are referred to neurosurgeons. In our center, and in most of the UK National Health Service system, “suspected cauda equina syndrome (CES)” cases are seen by out-of-hours neurosurgery services for urgent transfer and MRI scanning. The proportion of patients with a scan-positive CES (47/198 or 24%) was consistent with a systematic review (19%)2 and our retrospective study (28%).3

Background Nested within a large, multicenter randomized controlled trial (RCT) for people with dissociative seizures (DS), the study used purposive sampling to explore participants' experience of participating in an RCT, their experience of DS-specific cognitive behavioral therapy (CBT) and another component of the RCT, Standardized Medical Care (SMC) and their perceptions of and reflections on seizure management and change. Methods A qualitative study using semistructured interviews was conducted with 30 participants in an RCT (the COgnitive behavioral therapy vs standardized medical care for adults with Dissociative non-Epileptic Seizures (CODES) Trial) investigating the effectiveness of two treatments for DS. Key themes and subthemes were identified using thematic framework analysis (TFA). Results Analysis yielded three overarching themes: taking part in a treatment trial — “the only thing out there”, the experience of treatment techniques that were perceived to help with seizure management, and reflections on an “unpredictable recovery”. Conclusions People with DS are amenable to participating in a psychotherapy RCT and described a largely positive experience. They also described the applicability of aspects of DS-specific CBT and SMC in the management of their DS, received within the confines of the CODES trial. Factors that appeared to account for the variability in response to treatment delivery included individual preferences for the nature of sessions, the nature of therapeutic relationships, readiness to discuss trauma, other aspects of emotional avoidance, and whether therapy provided something new., Highlights • Participants generally perceived participating in an RCT as a positive experience. • Participants perceived that the CODES RCT offered them the possibility of change. • Breathing and distraction techniques were perceived to help with seizure management. • Participants identified the importance of a good therapeutic alliance. • Seizure control or acceptance of ongoing seizures was perceived as progress.

An increasing proportion of cognitive difficulties are recognized 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 conceptualized as a cognitive variant of functional neurological disorder, 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 recognized 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 individuals 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 personalized interventions.

Multiple sclerosis (MS) and functional neurological disorder (FND) are both diagnostically challenging conditions which can present with similar symptoms. We systematically reviewed the literature to identify patients with MS who were misdiagnosed with FND, patients with FND who were misdiagnosed with MS, and reports of patients with both conditions. In addition to FND, we included studies of patients with other functional and psychiatric disorders where these caused symptoms leading to investigation for or a diagnosis of MS, which in a different context would likely have been labeled as FND. Our review suggests that MS is one of the most common causes of misdiagnosis of FND and vice versa. We discuss the clinical errors that appear to result in misdiagnoses, such as over-reliance on psychiatric comorbidity when making a diagnosis of FND or over-reliance on neuroimaging for the diagnosis of MS, and practical ways to avoid them. Comorbidity between these two conditions is also likely common, has been poorly studied, and adds complexity to diagnosis and treatment in patients with both MS and FND. Misdiagnosis and comorbidity in a landscape of emerging evidence-based treatments for both MS and FND are issues not only of clinical importance to the care of these patients, but also to treatment trials, especially of MS, where FND could be a hidden confounder.

BackgroundPeople with functional neurological disorder (FND) are commonly seen by occupational therapists; however, there are limited descriptions in the literature about the type of interventions that are likely to be helpful. This document aims to address this issue by providing consensus recommendations for occupational therapy assessment and intervention.MethodsThe recommendations were developed in four stages. Stage 1: an invitation was sent to occupational therapists with expertise in FND in different countries to complete two surveys exploring their opinions regarding best practice for assessment and interventions for FND. Stage 2: a face-to-face meeting of multidisciplinary clinical experts in FND discussed and debated the data from stage 1, aiming to achieve consensus on each issue. Stage 3: recommendations based on the meeting were drafted. Stage 4: successive drafts of recommendations were circulated among the multidisciplinary group until consensus was achieved.ResultsWe recommend that occupational therapy treatment for FND is based on a biopsychosocial aetiological framework. Education, rehabilitation within functional activity and the use of taught self-management strategies are central to occupational therapy intervention for FND. Several aspects of occupational therapy for FND are distinct from therapy for other neurological conditions. Examples to illustrate the recommendations are included within this document.ConclusionsOccupational therapists have an integral role in the multidisciplinary management of people with FND. This document forms a starting point for research aiming to develop evidence-based occupational therapy interventions for people with FND.

Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD.Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients (n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ).Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism (p = 0.02), higher introversion (p = 0.008), lower conscientiousness (p = 0.03) and higher anxiety (p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients.Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.

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

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of the initial neuropsychiatric assessment of functional movement disorders (FND-movt) and functional limb weakness/paresis (FND-par) have yet to be established. This is an important gap from both diagnostic and treatment planning perspectives. In this article, the authors performed a narrative review to characterize clinically relevant variables across FND-movt and FND-par cohorts, including time course and symptom evolution, precipitating factors, medical and family histories, psychiatric comorbidities, psychosocial factors, physical examination signs, and adjunctive diagnostic tests. Thereafter, the authors propose a preliminary set of clinical content that should be assessed during early-phase patient encounters, in addition to identifying physical signs informing diagnosis and potential use of adjunctive tests for challenging cases. Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported. Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation. Positive physical examination signs (e.g., Hoover's sign and tremor entrainment) are key findings, as one of the DSM-5 diagnostic criteria. The neuropsychiatric assessment proposed emphasizes diagnosing FND by using "rule-in" physical signs while also considering psychiatric and psychosocial factors to aid in the development of a patient-centered treatment plan.

Performance validity tests (PVTs) are widely used in attempts to quantify effort and/or detect negative response bias during neuropsychological testing. However, it can be challenging to interpret the meaning of poor PVT performance in a clinical context. Compensation-seeking populations predominate in the PVT literature. We aimed to establish base rates of PVT failure in clinical populations without known external motivation to underperform. We searched MEDLINE, EMBASE and PsycINFO for studies reporting PVT failure rates in adults with defined clinical diagnoses, excluding studies of active or veteran military personnel, forensic populations or studies of participants known to be litigating or seeking disability benefits. Results were summarised by diagnostic group and implications discussed. Our review identified 69 studies, and 45 different PVTs or indices, in clinical populations with intellectual disability, degenerative brain disease, brain injury, psychiatric disorders, functional disorders and epilepsy. Various pass/fail cut-off scores were described. PVT failure was common in all clinical groups described, with failure rates for some groups and tests exceeding 25%. PVT failure is common across a range of clinical conditions, even in the absence of obvious incentive to underperform. Failure rates are no higher in functional disorders than in other clinical conditions. As PVT failure indicates invalidity of other attempted neuropsychological tests, the finding of frequent and unexpected failure in a range of clinical conditions raises important questions about the degree of objectivity afforded to neuropsychological tests in clinical practice and research.

Objectives: This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about “driving and psychogenic nonepileptic seizures (PNES)”; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive. Methods: Phase 1: Systematic literature review. Phase 2: Collection of international expert opinion using SurveyMonkey®. Experts included the members of the ILAE PNES Task Force and individuals with relevant publications since 2000. Phase 3: Joint analysis of the findings and refinement of conclusions by all participants using email. As an ILAE Report, the resulting text was reviewed by the Psychiatry Commission, the ILAE Task Force on Driving Guidelines, and Executive Committee. Results: Eight studies identified by the systematic review process failed to provide a firm evidence base for PNES-related driving regulations, but suggest that most health professionals think restrictions are appropriate. Twenty-six experts responded to the survey. Most held the view that decisions about driving privileges should consider individual patient and PNES characteristics and take account of whether permits are sought for private or commercial driving. Most felt that those with active PNES should not be allowed to drive unless certain criteria were met and that PNES should be thought of as “active” if the last psychogenic seizure had occurred within 6 months. Significance: Recommendations on whether PwPNES can drive should be made at the individual patient level. Until future research has determined the risk of accidents in PwPNES a proposed algorithm may guide decisions about driving advice. Fil: Asadi Pooya, Ali A.. Shiraz University Of Medical Sciences; Irán Fil: Nicholson, Timothy R.. King's College London; Reino Unido Fil: Pick, Susannah. King's College London; Reino Unido Fil: Baslet, Gaston. Harvard Medical School; Estados Unidos Fil: Benbadis, Selim R.. University Of South Florida; Estados Unidos Fil: Beghi, Massimiliano. Department of Mental Health; Italia Fil: Brigo, Francesco. Franz Tappeiner Hospital; Italia Fil: Buchhalter, Jeffrey. University of Calgary; Canadá Fil: D`alessio, Luciana. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Biología Celular y Neurociencia "Prof. Eduardo de Robertis". Universidad de Buenos Aires. Facultad de Medicina. Instituto de Biología Celular y Neurociencia; Argentina Fil: Dworetzky, Barbara. Harvard Medical School; Estados Unidos Fil: Gigineishvili, David. Tbilisi State University; Estados Unidos Fil: Kanaan, Richard A.. University of Melbourne; Australia Fil: Kozlowska, Kasia. University of Sydney; Australia Fil: LaFrance, W. Curt. University Brown; Estados Unidos Fil: Lehn, Alexander. Princess Alexandra Hospital; Australia Fil: Perez, David L.. Harvard Medical School; Estados Unidos Fil: Popkirov, Stoyan. No especifíca; Fil: Pretorius, Chrisma. No especifíca; Fil: Szaflarski, Jerzy P.. No especifíca; Fil: Tolchin, Benjamin. University of Yale; Estados Unidos Fil: Valente, Kette. Universidade de Sao Paulo; Brasil Fil: Stone, Jon. University of Edinburgh; Reino Unido Fil: Reuber, Markus. The University Of Sheffield; Reino Unido

Mild traumatic brain injury (TBI) is common and associated with a range of diffuse, non-specific symptoms including headache, nausea, dizziness, fatigue, hypersomnolence, attentional difficulties, photosensitivity and phonosensitivity, irritability and depersonalisation. Although these symptoms usually resolve within 3 months, 5%–15% of patients are left with chronic symptoms. We argue that simply labelling such symptoms as ‘postconcussional’ is of little benefit to patients. Instead, we suggest that detailed assessment, including investigation, both of the severity of the ‘mild’ injury and of the individual symptom syndromes, should be used to tailor a rehabilitative approach to symptoms. To complement such an approach, we have developed a self-help website for patients with mild TBI, based on neurorehabilitative and cognitive behavioural therapy principles, offering information, tips and tools to guide recovery: www.headinjurysymptoms.org.

ObjectivesWe aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes.MethodsA systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group.ResultsFive FND-specific measures were identified—three clinician-rated and two patient-rated—but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost–utility (eg, healthcare resource use and quality-adjusted life years).ConclusionsThere are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population.

Introduction: Functional motor disorders are often delineated according to the dominant motor symptom. In a large cohort, we aimed to find if there were differences in demographics, mode of onset, pain, fatigue, depression and anxiety and levels of physical functioning, quality of life and social adjustment between patients with different dominant motor symptoms. Methods: Baseline data from the Self-Help and Education on the Internet for Functional Motor Disorders Trial was used. Patients were divided into dominant motor symptom groups based on the diagnosis of the referring neurologist. Data on the above topics were collected by means of an online questionnaire and compared between groups using parametric and nonparametric statistics. Results: In 160 patients a dominant motor symptom could be determined, 31 had tremor, 45 myoclonus, 23 dystonia, 30 paresis, 31 gait disorder. No statistical differences between groups were detected for demographics, mode of onset and severity of pain, fatigue, depression and anxiety. Physical functioning was worse in the gait disorder group (median 20, IQR 25) compared to tremor (50 (55), p = 0.002) and myoclonus (50 (52), p = 0.001). Work and social adjustment was less impaired in the myoclonus group (median 20, IQR 18) compared to gait disorder (median 30, IQR18, p < 0.001) and paresis (28, IQR 10, p = 0.001). Self-report showed large overlap in motor symptoms. Conclusion: No differences were detected between groups of functional motor symptoms, regarding demographics, mode of onset, depression, anxiety, pain and fatigue. The large overlap in symptoms contributes to the hypothesis of shared underlying mechanisms of functional motor disorders.

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BACKGROUND AND PURPOSE There is large variability in the diagnostic approach and clinical management in functional movement disorders (FMD). This study aimed to examine whether opinions and clinical practices related to FMD have changed over the past decade. METHODS Adapted from a 2008 version, we repeated the survey to members of the International Parkinson and Movement Disorder Society (MDS). RESULTS In all, 864/7689 responses (denominator includes non-neurologists) were received from 92 countries. Respondents were more often male (55%), younger than 45 (65%) and from academic practices (85%). Although the likelihood of ordering neurological investigations prior to delivering a diagnosis of FMD was nearly as high as in 2008 (47% vs. 51%), the percentage of respondents communicating the diagnosis without requesting additional tests increased (27% vs. 19%; P = 0.003), with most envisioning their role as providing a diagnosis and coordinating management (57% vs. 40%; P

A history of head injury is common in patients with psychogenic nonepileptic seizures (PNES). This association has so far been interpreted as either spurious or psychologically mediated. Biased recall and misattribution could foster illness beliefs about brain damage that promote symptom production. Furthermore, the emotional impact of head injury could induce long-term changes in stress responsivity. Lastly, maladaptive cognitive-behavioural processes involving symptom modelling and aversive conditioning, known to play a role in functional neurological disorders, could contribute to the development of PNES after head trauma. Lesional effects of head injury, on the other hand, remain unexplored in the context of PNES. However, even mild traumatic brain injury without structural MRI abnormalities on routine imaging can lead to disruptions of network connectivity that correlate with short-term cognitive impairments and psychiatric symptoms. Since alterations in global functional connectivity have been demonstrated in PNES patients using imaging and electroencephalography, we hypothesize that, in some patients, TBI and the associated disruption of long-range association fibres could contribute to the individual propensity for dissociative experiences in general and PNES in particular. This possibility is explored in the context of new cognitive-behavioural models of PNES pathogenesis, and the concept of a "dissociogenic" brain lesion is introduced.