Expert Witness Journal Dec 24 - Journal - Page 23
Functional Cognitive Disorder
(FCD) in Personal Injury
Dr Tracey Ryan-Morgan & Yasmin Hiscox
Talis Consulting Limited
“perpetrator”, low mood and, sometimes, medication
(Phillips, 2021), referred to as iatrogenic effects.
What is Functional Cognitive Disorder?
Functional Cognitive Disorder (FCD) is described as
an interface disorder between Neurology, Neuropsychology and Neuropsychiatry. It has been defined as
occurring when, “patients present… with significant
subjective cognitive symptoms that are out of keeping with their
observed level of cognitive functioning and not compatible
with a recognizable neurodegenerative, psychiatric or systemic
primary cause” (p.1, Pennington et al, 2019). Put simply,
the person experiences abnormal function but their
biological system is capable of normal function.
What does FCD look like and how do we assess it?
There are three main groups of symptoms to look out
for if FCD is suspected:
• Somatic hypervigilance and somatization – this is
where the person effectively engages in “symptom
watching”. Ven den Burgh et al (2017) refer to it as
the person having a “somatic attribution bias” (p.189).
• Negative illness beliefs leading to excessive
self- monitoring which, in turn, leads to confirmatory
bias. Van den Burgh et al (2017) refer to this as taking
an “inferential leap” (p.186).
How do we understand FCD?
Functional disorders, of which FCD is a form of
symptom expression, used to be seen as a diagnosis of
exclusion, that is, when everything else (physical) is
ruled out and when the only remaining explanation
or diagnosis is that of a functional problem. However,
in recent years, there has been a considerable shift in
thinking around such clinical presentations and it is
now seen as a positive diagnosis based on clinical findings. This should, and often does, now lead to an earlier diagnosis which, in turn, should positively affect
the person’s prognosis.
• “Cogniphobia” leading to avoidance behaviours and
also to resistance to reassurance that there is a
reasonable (alternative) explanation which could
apply (Teodoro et al, 2018).
This has led to some researchers suggesting that there
may be a broad phenotype which presents with FCD
(McWhirter et al, 2020) although there are those that
would disagree (Toedoro et al, 2018; Kemp et al,
2022).
What causes FCD and why do some people get it and
some people don’t?
Functional Neurological Disorder (FND) is the
umbrella descriptor from which other functional
labels, such as FCD, derive. Phillips (2021) refers to
FND as when neurological symptoms have no structural (organic) substrate. Historically, functional disorders were believed to be caused by a triggering
event (Keynejad et al, 2019) such as a concussive injury (physical) or a trauma (psychological) which were
then maintained by a psychological response to that
index event. More recently, it has been acknowledged
that FCD can arise in the absence of either a remote or
proximal trauma. In the medicolegal context, this
means that claimants who develop functional symptoms may do so due to a pre-existing vulnerability or
predisposition to do so. This suggests the possibility
that FCD may emerge spontaneously (Phillips, 2021).
In such cases, it will be critically important to separate
out the pre-disposing factors from the symptoms
which emerge. Predisposing factors can include anxiety, depression, ADHD, substance misuse or previous
adverse experiences (Stone et al, 2020; Clark et al,
2022; Ryan-Morgan, 2023). Post-FCD factors, which
are believed to perpetuate or worsen symptoms, can
include social, financial or other secondary gain,
(referred to as “compensation neurosis” by Levy, 1992),
perfectionism, fixed beliefs or illness expectations,
poor sleep, chronic pain, anger towards a
EXPERT WITNESS JOURNAL
The means of assessing whether FCD is relevant to a
claimant is to include a robust clinical interview, including history from involving multiple sources, the
completion of self-report questionnaires, objective
psychometric testing (including performance validity
testing). Kemp et al (2022) demonstrate that FCD patients often exhibit a profile of test results that are
readily explained by anxiety, do not conform to an expected pattern, or may not be congruent with the person’s premorbid level of capabilities.
What’s the difference between FCD and
malingering or exaggerating?
There are three main areas of differentiation
(although Kemp et al, 2022, describe five potential
symptom categories).
The first step is to assess whether or not there are genuine cognitive impairments. This can be established
through comprehensive neuropsychological assessment as referred to in the section above. If the clinical
presentation and assessment results point to an established pattern of cognitive dysfunction with a known
neurological or neuropathological substrate, then the
assessment will have established, on the balance of
probabilities, that the complaints are consistent, making “neuropsychological, biological or psychometric sense”
(Ryan-Morgan, 2012).
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DECEMBER 2024
