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Objective\ud Dissociative traits represent a disturbance in selfhood that may predispose to, and trigger, functional seizures (FSs). The predictive representation and control of the internal physiological state of the body (interoception) are proposed to underpin the integrity of the sense of self (“minimal selfhood”). Therefore, discrepancies between objective and subjective aspects of interoception may relate to symptom expression in patients with FSs. Here, we tested whether individual differences in trait measures of interoception relate to dissociative symptoms, and whether state interoceptive deficits predict FS occurrence.\ud \ud Methods\ud Forty‐one participants with FSs and 30 controls completed questionnaire ratings of dissociation, and measures of (1) interoceptive accuracy (IA)—objective performance on heartbeat detection tasks; (2) trait interoceptive sensibility—subjective sensitivity to internal sensations (using the Porges Body Perception Questionnaire); and (3) state interoceptive sensibility—subjective trial‐by‐trial measures of confidence in heartbeat detection. Interoceptive trait prediction error (ITPE) was calculated from the discrepancy between IA and trait sensibility, and interoceptive state prediction error (ISPE) from the discrepancy between IA and state sensibility.\ud \ud Results\ud Patients with FSs had significantly lower IA and greater trait interoceptive sensibility than healthy controls. ITPE was the strongest predictor of dissociation after controlling for trait anxiety and depression in a regression model. ISPE correlated significantly with FS frequency after controlling for state anxiety.\ud \ud Significance\ud Patients with FSs have disturbances in interoceptive processing that predict both dissociative traits reflecting the disrupted integrity of self‐representation, and the expression of FSs. These findings provide insight into the pathophysiology of functional neurological disorder, and could lead to novel diagnostic and therapeutic approaches.

Functional neurological disorder (FND) is a common diagnosis in neurology clinics, and there is some evidence psychological therapy can be of benefit. Eye movement desensitization and reprocessing therapy (EMDR) is a well-evidenced treatment for posttraumatic stress disorder (PTSD), and there is increasing evidence that it is beneficial for other conditions. EMDR is a therapy designed to focus on distressing memories, and therefore can be used for non-PTSD presentations where distressing memories are relevant. There is a small amount of case study evidence that EMDR can be used successfully with FND presentations and comorbid PTSD. This article describes two illustrative case examples of people diagnosed with FND who have distressing memories relevant to their presentation. Presenting functional symptoms included functional non-epileptic attacks and functional sensory symptoms. Psychological treatment-as-usual plus EMDR resulted in improvements for both cases and demonstrated that EMDR is a promising additional treatment option for FND presentations, appropriately selected. Recommendations regarding further research are made.

SUMMARYWe review the various functional cognitive disorders (FCDs) – complaints about memory function or another cognitive process in the absence of relevant neuropathology. These are increasingly coming to the attention of psychiatrists and neurologists and FCD encompasses some newly recognised conditions in addition to classic types such as pseudodementia and psychogenic amnesia. The clinical features, neuropsychological findings and treatment are presented and discussed.LEARNING OBJECTIVESAfter reading this article you will be able to: •describe clinical features of FCD and how it differs from neurodegenerative causes of cognitive impairment•be able to subclassify cases of FCD using the proposed nosology•understand how to discuss the diagnosis with the patient and explain how the symptoms arise.

Referred to by the ancient Greeks as ‘Hysteria’, functional neurological disorders (FNDs) are one of the most prevalent diagnoses made in neurology clinics. Nonetheless, in part, due to the uncertainty regarding the potential voluntariness of such conditions, diagnostic and treatment services for FNDs are underdeveloped by comparison to those for other causes of neurological symptoms. This chapter discusses historical approaches to the classification and approach to FNDs, before moving on to contemporary treatments for it. Various treatments are then described with regard to certain forms of FNDs, such as the effects of cognitive behavioural therapy (CBT) and psychodynamic interpersonal therapy on functional non-epileptic attacks and multidisciplinary inpatient treatment, physiotherapy, and hypnosis on functional motor disorder. Finally, the relative lack of treatment options for functional cognitive disorder (FCD) is discussed, along with the initial findings of a pilot randomized controlled trial for it.

There is considerable debate in the literature regarding what to call functional seizures, with terms such as pseudoseizures, nonepileptic attack disorder (NEAD), and dissociative seizures being used. Provision of an accurate diagnosis and coherent explanation is a vital first step in the management of functional seizures and can result in cessation or reduced frequency for some individuals. This study investigated preferences for and offensiveness of terms used to describe functional seizures, and expectations for recovery with psychological treatment. A sample of 87 healthy adults completed an online survey, in which eight different diagnostic terms were ranked in order of preference (1 — most preferred, 8 — least preferred): functional nonepileptic attacks (FNEA), dissociative seizures, functional seizures, psychogenic seizures, NEAD, pseudoseizures, conversion disorder, and hysteria. Replicating Stone and colleagues protocol, each term was investigated for five connotations. Offense scores were calculated from the number of participants who selected ‘yes’ to at least one of the negative connotations (‘Putting it on’, ‘Mad’, and ‘Imagining Symptoms’). Expectations about the possibility of recovering through medical or psychological treatment were also recorded. Functional nonepileptic attack was ranked the highest preferred term with dissociative seizures and functional seizures closely following. Nonepileptic attack disorder was the least offensive term, with FNEA and functional seizures joint second. Unsurprisingly, the three least preferred terms were also the most offensive: pseudoseizures, conversion disorder, and hysteria. Expectations of nonrecovery from psychological treatment were lowest for terms implicating a psychological cause: pseudoseizures, dissociative seizures, psychogenic seizures, and hysteria. The results suggest that either the terms FNEA or functional seizures should be adopted by healthcare professionals and patients, as they are the most preferred, least offensive, and expectations for nonrecovery with psychological treatment were moderate compared with the other terms. Limitations and areas for future research are discussed.

Patients who experience functional non-epileptic attacks (FNEA) are frequently seen in Neurology clinics. Diagnosis alone can result in cessation of attacks for some patients, but many patients require further treatment. There is evidence that certain psychological therapies, like cognitive-behavioral therapy (CBT) and psychodynamic interpersonal therapy (PIT) can be beneficial. Acceptance and commitment therapy (ACT) is a type of CBT that has been found to be effective at treating other somatic disorders, like epilepsy and chronic pain. In this paper, we explain what ACT is, the current evidence-base for its use, and the rationale for why it may be a beneficial treatment for patients who experience FNEA. We conclude that ACT is a potential treatment option for FNEA, and further research is required.

A high proportion of patients presenting at epilepsy clinics experience functional non-epileptic attacks (FNEA), and while psychological treatment is generally thought to be the required intervention, evidence regarding psychological treatment of FNEA is limited. A small number of psychoeducation treatments have been evaluated, with promising results. As part of routine care within a neuropsychiatry service, a 3-session cognitive-behavior therapy- (CBT-) informed psychoeducation group was developed. Patients with comorbid epilepsy were included. The group's effectiveness was evaluated in terms of attack frequency, mood, illness perception, dissociative experiences, and patient feedback. Pre- and post-treatment data were obtained for 19 patients. The proportion of patients experiencing attacks significantly decreased, with almost 40% of treatment completers reporting being attack-free at the end of treatment. Significant improvements were also found on level of psychological distress, illness beliefs, and understanding of the condition. No significant changes in mood or general functioning were observed. High satisfaction was reported by almost all patients. Treatment outcome was not significantly affected by the level of dissociative experiences. The results suggest that CBT-based psychoeducation group treatment can be a beneficial part of treatment for those with FNEA, even for those experiencing high levels of dissociation. Further controlled studies with larger sample sizes are required.

Objectives The continuity and integrity of a conscious sense of self, is proposed to be dependent upon the control of internal physiological state and its predictive representation through interoception, that is, the sensing of internal bodily changes. We investigated dissociation, interoception and their relationship, in patients with functional seizures (FS), before and after a stressor intervention. Methods 41 participants with functional seizures (FS) and 30 age/gender matched healthy controls (HC) were assessed with the somatoform dissociation questionnaire (SDQ20), multi-scale dissociation inventory (MDI), and the state and trait anxiety inventory (STAI). Standardized measures of interoceptive sensibility, accuracy, and awareness were acquired with the Porges Body Perception Questionnaire (PBPQ), and heartbeat discrimination (HDT), tracking (HTT) and time-tracking tasks (TTT), before and after a cold pressor test. Continuous non-invasive blood pressure monitoring was carried out before, during and after the cold pressor test. Interoceptive trait (ITPE) and state (ISPE) prediction errors, that is, the discrepancy between interoceptive accuracy and the PBPQ (trait), and trial-by-trial confidence estimates (state), were calculated before and after the cold pressor test respectively, for HTT and HDT. An autonomic prediction error (APE), or the discrepancy between the reported increase in pain and the change in blood pressure after the cold pressor, was also calculated. Results Patients with FS differ significantly from HC for HTT, ITPE and ISPE suggesting that they are overall less interoceptively accurate and aware than HC. This is confirmed by a correlation between APE and the ISPE derived from the HDT task (r=0.359, p=0.033) in FS subjects only, after correcting for state anxiety and duration of cold pressor. Furthermore, in FS patients only, ITPE scores, adjusted for trait anxiety, correlated with SDQ-20 and MDI-depersonalization scores for both HTT (r=0.378, p=0.008; r=0.408, p=0.005) and HDT (r=0.364, p=0.011; r=0.281, p=0.044). All results survived FDR correction at a 0.05 threshold. Conclusions These findings demonstrate that state and trait interoception are disrupted in patients with FS. The severity of the disruption in trait interoception correlates with measures of dissociation, such that the bigger the ITPE, the more severe are the dissociative traits. Similarly, the greater the ISPE, the larger the discrepancy between subjective symptoms and objective physiological changes, after a stressor intervention. Our findings suggest that the selective disruption of interoceptive processing is both a potential predisposing and precipitating factor in FS.

Summary Objective Functional seizures are a common functional neurologic disorder. Given their chronic nature, and the biopsychosocial factors involved in their etiology, general practitioners (GPs) play a crucial role in the care of these patients. However, little is known about the attitudes of GPs toward, and knowledge of, functional seizures. Methods The Atkinson Morley Regional Neuroscience Centre in London provides a comprehensive service to patients with functional seizures. As part of a service evaluation we conducted an online survey among local GPs over a 1‐month period assessing their attitudes toward, and knowledge of, functional seizures. Results One hundred twenty of 974 surveyed GPs replied to the survey (12.3%). Approximately 75% of GPs readily use the term “pseudoseizures,” and over 50% were not sure or did not think that functional seizures were involuntary. Nearly 30% believed, or were unsure as to whether, functional seizures occur only when patients are stressed. Despite approximately 50% of GPs expressing interest in getting involved in the management of these patients, a similar proportion do not feel confident in dealing with queries from patients with functional seizures. Although most GPs felt that neurology and psychiatry should be the primary caregivers in the diagnosis and management, respectively, of functional seizures, 50% were also of the opinion that neurology should be involved in the management of these patients. Significance This survey highlights the attitudes of, and descriptive terms used by, GPs toward patients with functional seizures. Our findings suggest a need for better and clearer provision of information to GPs about this condition.

This study explored the preferred terms for functional seizures, and the experience of being diagnosed, from the patient’s perspective. 39 patients in a neuropsychiatry service diagnosed with functional seizures completed an online survey to investigate preferences for, and offensiveness of, 11 common diagnostic terms used to describe functional seizures. Of these 39 patients, 13 consented to take part in a semistructured interview exploring the experience of receiving a diagnosis. Nonepileptic attack disorder (NEAD), functional seizures, functional nonepileptic attacks (FNEA), and dissociative seizures were ranked the highest preferred terms and did not significantly differ from one another. NEAD was the least offensive term, with functional seizures and FNEA following closely. Significant overlap in confidence intervals was found between the offensiveness of all terms. Terms that indicated a psychological origin were the least preferred and viewed as most offensive. Thematic analysis identified three main themes on the experience of being diagnosed: ‘being heard and having a shared understanding’, ‘feeling alone’, and ‘sense of hope’. Patients favored diagnostic terms that facilitated and alleviated these themes on a personal basis; however, preferences differed across individuals. Our findings suggest that a range of terms have a similar level of preference and offense rating, with NEAD, functional seizures, and FNEA being the most favorable. Qualitative analysis indicates that a term and its accompanying explanation should facilitate shared acceptance and understanding, and several terms provide this. In combination with our previous study on healthy participants, we propose that one of the two terms researched are adopted by patients, health professionals, and the public: Functional nonepileptic attacks or Functional seizures.