Expert Witness Journal Dec 24 - Journal - Page 24
If, however, the outcome of the assessment is that
there are discrepancies between these assessment elements, then the diagnostician must look further. A key
differentiating factor at this stage is whether or not the
claimant has passed the performance validity element
of the assessment. This is critical to establishing
whether the claimant is exerting willful or voluntary
control over the reported symptoms or not. It has
been established in the literature that patients with
FCD tend to pass effort tests whereas those who are
feigning or dissimulating do not (Slick et al, 1999,
Sherman et al, 2020; British Psychological Society,
2009 & 2021, Kemp et al, 2022). Those with a nonorganic basis to their clinical presentation may give extensive, and often elaborate, accounts of their memory
failures without being alive to the incongruity of this.
It often does not occur to such patients that reeling off
a list, from memory, of their self-observed mnestic failings does not make sense. It has been reported in the
literature that patients with FCD may also not engage
thoroughly with testing and are often observed to give
up quickly, choosing to repeat their perceived cognitive symptoms (Kemp et al, 2022). It is not unusual to
hear a claimant state that, “I’ll never be able to do this” or
”my memory is rubbish” before even starting a test.
Significant others can assist with challenging avoidant
behaviours by encouraging and reinforcing progress.
Those who deliberately feign memory difficulties are
relatively straightforward to identify in clinical assessment (Alexander et al, 2019) as they tend to fail performance validity testing fairly spectacularly (well
below what would be expected by chance). However,
what the clinician cannot do, with any certainty or reliability, is to establish the person’s motives for doing
so. That is for the Court to determine, if it accepts the
expert opinion.
1. Alexander, M; Blackburn, D. & Reuber, M. (2019).
Patients’ accounts of memory lapses in interactions between
neurologists and patients with functional memory disorders.
Sociology of health & Illness, 41, (20) pp249-265.
What about prognosis?
The above treatment allows the claimant a “preferred
future” by asking questions like, “how good would it
be if you could go back to doing xx?” or “how good
would you feel if you were able to do xxx?”. Research
has shown that involving patients with a confirmed
FCD diagnosis in a treatment partnership with their
clinician is the most effective way of treating this disorder (Stone et al, 2020). Utilising a non-judgemental
approach and neutral language helps to avoid
the sense of not being believed or the worry that
symptoms will not be seen as genuine or credible.
There is published evidence that points to cases where
continued grievance (usually against a perceived perpetrator) further adds to symptom entrenchment
(Wood, 2007 in Phillips, 2021) which can result in a
more guarded prognosis.
FCD remains a growing area of research and practice
and further developments are expected. Watch this
space.
Selected references:
2. British Psychological Society: Professional Practice Board
(2009). Assessment of effort in clinical testing of cognitive
functioning for adults. BPS publication, Leicester, UK
3. British Psychological Society: Professional Practice
Board (2021). Guidance on the assessment of
performance validity in neuropsychological assessments.
BPS publication, Leicester, UK.
How is FCD treated?
Management of FCD is primarily psychological.
Firstly, treatment has to start with education around
the normalization of cognitive failures in the general
population and also to confirm, with the claimant, the
reversibility of symptoms (Teodoro et al, 2018;
McWhirter et al, 2020, Kemp et al, 2022).
4. Clark, C; Edwards, M; Ong, B; Goodliffe, L; Ahmad,
H; Dilley, M; Betteridge, S; Griffin, C. & Jenkins, P. (2022).
Reframing post-concussional syndrome as an interface
disorder of neurology, psychiatry and psychology. Brain,
https://doi.org/10.1093/brain/awac149
5. Kemp, S; Kapur, N; Graham, C. & Reuber, M. (2022).
Functional Cognitive Disorder: differential diagnosis of
common clinical presentations. Archives of Clinical
Neuropsychology. https://doi.org/10.1093/arclin/acac020
The second stage of treatment will continue by
challenging the person’s beliefs concerning their
symptoms by working together to unpick and reframe
beliefs around self-reported symptoms. This is undertaken by tasking the person to obtain evidence that
will divert them into different perspectives of their
symptoms. This will assist them to move away from
the catastrophic beliefs that underpin FCD by counterbalancing them with the Positive Psychology
approach (Seligman & Csikszentmihalyi, 2000).
6. Keynejad, R; Frodl, T; Kanann, R; Pariante, C; Rueber,
M. & Nicholson, T. (2019). Stress and functional neurological disorders: mechanistic insights. Journal of Neurology,
Neurosurgery & Psychiatry, (90), pp.813-821.
https://doi.org/10.1136/jnnp-2018-318297
7. McWhirter, L; Ritchie, C; Stone, J. & Carson, A. (2020).
Functional Cognitive Disorders: a systematic review.
Lancet Psychiatry. https://doi.org/10.1016/s22150366(19)30405-5
Thirdly, the treatment works on helping the person
to regain mastery by reducing their physiological
arousal which will, in turn, lower their levels of vigilance and symptom watching (Ven den Burgh et al,
2017).
8. Pennington, C; Ball, H. & Swirski, M. (2019). Functional
cognitive disorder: diagnostic challenges and future
directions. Diagnostics. https://doi.org/10.3390/diagnostics
9040131
9. Phillips, W. (2021). Functional neurological disorders in
personal injury. British Medical Journal Neurology Open.
https://doi.org/10.1136/bmjno-2020-000100
Alongside all of these elements of treatment, the
clinician will work with the “system” around the
patient, such as partner, parents or adult children, to
reduce their (often inadvertent) contribution to the
behaviours which perpetuate unhelpful beliefs.
EXPERT WITNESS JOURNAL
10. Ryan-Morgan, T. (2012). Evidence-based Neuropsychological Assessment: Grant Iverson Workshop, Division
of Neuropsychology Newsletter (August, Volume 11, issue
2 pp. 4-5).
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DECEMBER 2024
