Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study.

BACKGROUND: Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions. METHODS: International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken. RESULTS: Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%-88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%-92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD. CONCLUSIONS: Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions.

Individual differences in emotion-induced blindness: Are they reliable and what do they measure?

The emotion-induced-blindness (EIB) paradigm has been extensively used to investigate attentional biases to emotionally salient stimuli. However, the low reliability of EIB scores (the difference in performance between the neutral and emotionally salient condition) limits the effectiveness of the paradigm for investigating individual differences. Here, across two studies, we investigated whether we could improve the reliability of EIB scores. In Experiment 1, we introduced a mid-intensity emotionally salient stimuli condition, with the goal of obtaining a wider range of EIB magnitudes to promote reliability. In Experiment 2, we sought to reduce the attentional oddball effect, so we created a modified EIB paradigm by removing the filler images. Neither of these approaches improved the reliability of the EIB scores. Reliability for the high- and mid-intensity EIB difference scores were low, while reliability of the scores for absolute performance (neutral, high-, and mid-intensity) were high and the scores were also highly correlated, even though overall performance in the emotionally salient conditions were significantly worse than in the neutral conditions. Given these results, we can conclude that while emotionally salient stimuli impair performance in the EIB task compared with the neutral condition, the strong correlation between the emotionally salient and neutral conditions means that while EIB can be used to investigate individual differences in attentional control, it is not selective to individual differences in attentional biases to emotionally salient stimuli.

Specialist physiotherapy for functional motor disorder in England and Scotland (Physio4FMD): a pragmatic, multicentre, phase 3 randomised controlled trial.

BACKGROUND: Functional motor disorder-the motor variant of functional neurological disorder-is a disabling condition that is commonly associated with poor health outcomes. Pathophysiological models have inspired new treatment approaches such as specialist physiotherapy, although evidence from large randomised controlled trials is absent. We aimed to assess the clinical effectiveness of a specialist physiotherapy intervention for functional motor disorder compared with treatment as usual. METHODS: In this pragmatic, multicentre, phase 3 randomised controlled trial at 11 hospitals in England and Scotland, adults with a clinically definite diagnosis of functional motor disorder, diagnosed by a neurologist, were included. Participants were randomly assigned (1:1, stratified by site) using a remote web-based application to either specialist physiotherapy (a protocolised intervention of nine sessions plus follow-up) or treatment as usual (referral to local community neurological physiotherapy). Individuals working on data collection and analysis were masked to treatment allocation. The primary outcome was the physical functioning domain of the 36-item short form health questionnaire (SF36) at 12 months after randomisation. The primary analysis followed a modified intention-to-treat principle, using a complete case approach; participants who were unable to receive their randomised treatment due to the suspension of health-care services during the COVID-19 pandemic were excluded from the primary analysis. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN56136713, and is completed. FINDINGS: Recruitment occurred between Oct 19, 2018, and March 11, 2020, pausing during the COVID-19 lockdown, and resuming from Aug 3, 2021, to Jan 31, 2022. Of 355 participants who were enrolled, 179 were randomly assigned to specialist physiotherapy and 176 to treatment as usual. 89 participants were excluded from the primary analysis due to COVID-19 interruption to treatment (27 were assigned to specialist physiotherapy and 62 to treatment as usual). After accounting for withdrawals (n=11) and loss to follow-up (n=14), the primary analysis included data from 241 participants (138 [91%] assigned specialist physiotherapy and 103 [90%] assigned treatment as usual). Physical functioning, as assessed by SF36, did not differ significantly between groups (adjusted mean difference 3·5, 95% CI -2·3 to 9·3; p=0·23). There were no serious adverse events related to the trial interventions. 35 serious adverse events were recorded in the specialist physiotherapy group by 24 participants (17·0%), and 24 serious adverse events were recorded in the treatment as usual group by 18 participants (17·0%); one death occurred in the specialist physiotherapy group (cause of death was recorded as suicide). All were considered unrelated to specialist physiotherapy. INTERPRETATION: Although more participants who were assigned specialist physiotherapy self-rated their motor symptoms as improved and had better scores on subjective measures of mental health, the intervention did not result in better self-reported physical functioning at 12 months. Both the specialist and community neurological physiotherapy appeared to be a safe and a valued treatment for selected patients with functional motor disorder. Future research should continue to refine interventions for people with functional motor disorder and develop evidence-based methods to guide treatment triage decisions. FUNDING: National Institute for Health and Care Research and Health Technology Assessment Programme.

Reducing airborne transmissible diseases in perioperative environments.

The COVID-19 pandemic has transformed our understanding of aerosol transmissible disease and the measures required to minimise transmission. Anaesthesia providers are often in close proximity to patients and other hospital staff for prolonged periods while working in operating and procedure rooms. Although enhanced ventilation provides some protection from aerosol transmissible disease in these work areas, close proximity and long duration of exposure have the opposite effect. Surgical masks provide only minimal additional protection. Surgical patients are also at risk from viral and bacterial aerosols. Despite having recently experienced the most significant pandemic in 100 yr, we continue to lack adequate understanding of the true risks encountered from aerosol transmissible diseases in the operating room, and the best course of action to protect patients and healthcare workers from them in the future. Nevertheless, hospitals can take specific actions now by providing respirators for routine use, encouraging staff to utilise respirators routinely, establishing triggers for situations that require respirator use, educating staff concerning the prevention of aerosol transmissible diseases, and providing portable air purifiers for perioperative spaces with low levels of ventilation.

Perioperative oxygenation-what's the stress?

Oxygen is the most used drug in anaesthesia. Despite such widespread use, optimal perioperative oxygen administration remains highly controversial because of concerns about the competing harms of both hyperoxia and hypoxia. Notwithstanding a Cochrane review concluding that routinely administering a fractional inspired oxygen concentration (FiO2) >0.6 intraoperatively might increase postoperative morbidity and mortality, the World Health Organization (WHO) currently recommends all anaesthetised patients receive 0.8 FiO2 during and immediately after surgery to reduce surgical site infections. Results from the largest trial available at the time of these two reviews (suggesting long-term survival may be worse with high FiO2, particularly in patients with malignant disease) were considered 'biologically implausible' by the WHO's Guideline Development Group. In addition, the integrity of some perioperative oxygen studies has been challenged. Resolving these controversies is of fundamental importance to all perioperative clinicians. This narrative review is based on the inaugural BJA William Mapleson lecture delivered by the senior author (AC) at the 2023 annual meeting of the Royal College of Anaesthetists in Birmingham. We present the current evidence for perioperative oxygen administration and contrast this with how oxygen therapy is targeted in other specialties (e.g. intensive care medicine). We will explore whether anaesthetists follow the WHO recommendations and consider how oxygen administration affects the stress response to surgery. We reason that novel clinical trial designs in combination with targeted experimental medicine studies will be required to improve our understanding of how best to optimise individualised perioperative oxygenation-a cornerstone of anaesthesia.

What are the experiences of people with motor and sensory functional neurological disorder? A systematic review and thematic synthesis of qualitative studies.

PURPOSE: Functional neurological disorders are common, highly stigmatised and associated with significant disability. This review aimed to synthesise qualitative research exploring the experiences of people living with motor and/or sensory FND. Identifying their needs should inform service development, education for healthcare professionals and generate future research questions. METHOD: Five databases were systematically searched (Medline, PsychInfo, Web of Science, Embase and Cinahl) in November 2022, updated in June 2023. Data from included papers was extracted by two authors and studies were critically appraised using the Critical Appraisal Skills Programme (CASP). Data was thematically analysed and synthesised. RESULTS AND CONCLUSIONS: 12 papers were included in the synthesis describing the views of 156 people with FND. The overarching theme was uncertainty; about what caused FND and how to live with it. Uncertainty was underpinned by four analytic themes; challenging healthcare interactions, loss of power and control, who or what is responsible and living with a visible disability and an invisible illness. Early and clear diagnosis, validation and support for living with FND should form part of multidisciplinary care. Co-produced service development, research agendas and education for clinicians, patients and the public would reduce stigma and improve the experiences of people with FND.

A clear diagnosis and explanation of motor and/or sensory functional neurological disorder is validating and an important first step in recovery.People with motor and/or sensory functional neurological disorder experience significant disability, stigma, self-blame and functional impairment.Multidisciplinary care pathways for functional neurological disorder urgently need to be developed.There is a need for co-produced education and training for healthcare professionals which covers how to deliver diagnoses and personalised formulations, communicate concepts of applied neuroscience and challenges stigma and discrimination.

Etiological Factors and Symptom Triggers in Functional Motor Symptoms and Functional Seizures: A Pilot Investigation.

OBJECTIVE: This study examined etiological factors and symptom triggers of functional motor symptoms (FMS) or functional seizures (FS) and assessed potential relationships with relevant clinical features (i.e., functional symptoms, quality of life, and general functioning). METHODS: Seventeen participants with FMS or FS and 17 healthy control participants underwent an in-depth clinical interview and completed questionnaires assessing adverse life events, psychological and physical symptoms, alexithymia, autistic traits, illness perceptions, health-related quality of life (HRQoL), and work and social functioning. RESULTS: Participants with FMS or FS perceived various causes of the disorder, including physical symptoms (65%), emotional problems (53%), adverse life events (47%), and work-related factors (29%). Triggers of FMS and FS included physical activity or exertion (59%), stress and emotions (59%), sensory experiences (47%), and fatigue (41%). Compared with healthy control participants, participants with FMS or FS reported more adverse events during adolescence and higher levels of alexithymia, somatoform dissociation, psychological dissociation (disengagement, depersonalization, and derealization), anxiety, depression, and physical symptoms. Participants with FMS or FS had worse HRQoL than healthy control participants and impaired work and social functioning. There were inverse associations between HRQoL scores and somatoform dissociation, anxiety, and adverse life events. CONCLUSIONS: Participants with FMS or FS reported diverse biopsychosocial etiological factors and symptom triggers. Ongoing psychological symptoms and lifetime adverse experiences were associated with worse HRQoL. Future studies will examine these factors in larger samples of individuals with FMS or FS to better understand their shared and distinct etiological underpinnings.

From Software to Hardware: A Case Series of Functional Neurological Symptoms and Cerebrovascular Disease.

OBJECTIVE: Neuroimaging studies have identified alterations in both brain structure and functional connectivity in patients with functional neurological disorder (FND). For many patients, FND emerges from physical precipitating events. Nevertheless, there are a limited number of case series in the literature that describe the clinical presentation and neuroimaging correlates of FND following cerebrovascular disease. METHODS: The authors collected data from two clinics in the United Kingdom on 14 cases of acute, improving, or delayed functional neurological symptoms following cerebrovascular events. RESULTS: Most patients had functional neurological symptoms that were localized to cerebrovascular lesions, and the lesions mapped onto regions known to be part of functional networks disrupted in FND, including the thalamus, anterior cingulate gyrus, insula, and temporoparietal junction. CONCLUSIONS: The findings demonstrate that structural lesions can lead to FND symptoms, possibly explained through changes in relevant mechanistic functional networks.

Simultaneous estimation of the temporal and spatial extent of animal migration using step lengths and turning angles.

BACKGROUND: Animals of many different species, trophic levels, and life history strategies migrate, and the improvement of animal tracking technology allows ecologists to collect increasing amounts of detailed data on these movements. Understanding when animals migrate is important for managing their populations, but is still difficult despite modelling advancements. METHODS: We designed a model that parametrically estimates the timing of migration from animal tracking data. Our model identifies the beginning and end of migratory movements as signaled by change-points in step length and turning angle distributions. To this end, we can also use the model to estimate how an animal's movement changes when it begins migrating. In addition to a thorough simulation analysis, we tested our model on three datasets: migratory ferruginous hawks (Buteo regalis) in the Great Plains, barren-ground caribou (Rangifer tarandus groenlandicus) in northern Canada, and non-migratory brown bears (Ursus arctos) from the Canadian Arctic. RESULTS: Our simulation analysis suggests that our model is most useful for datasets where an increase in movement speed or directional autocorrelation is clearly detectable. We estimated the beginning and end of migration in caribou and hawks to the nearest day, while confirming a lack of migratory behaviour in the brown bears. In addition to estimating when caribou and ferruginous hawks migrated, our model also identified differences in how they migrated; ferruginous hawks achieved efficient migrations by drastically increasing their movement rates while caribou migration was achieved through significant increases in directional persistence. CONCLUSIONS: Our approach is applicable to many animal movement studies and includes parameters that can facilitate comparison between different species or datasets. We hope that rigorous assessment of migration metrics will aid understanding of both how and why animals move.

A Critical Appraisal of the Whack-a-Mole and Swivel Chair Signs in the Diagnosis of Functional Movement Disorders.

BACKGROUND: The demonstration of positive signs during neurological examination is a cornerstone of the diagnosis of functional movement disorders, however, the available data supporting the diagnostic value of some of these signs is limited. OBJECTIVES: To determine the diagnostic value (sensitivity and specificity) of the "whack-a-mole" (WAM) and "swivel chair" (SC) tests in patients with functional movement disorders (FMD). METHODS: We enrolled patients with functional and organic movements in the WAM test if they exhibited tremor, dystonia, myoclonus, chorea, or tics. For the SC test, patients with a gait disorder as their primary impairment were recruited. Two blinded movement disorder specialists rated the presence of these signs in edited videos. RESULTS: Inclusion criteria were met by 42 patients with FMD and 65 patients with organic movement disorders. Both tests demonstrated high specificity (means, 78% and 96%), but their sensitivity was low (means, 52% and 37%). Interobserver agreement for the WAM sign was 0.77 in the FMD group, against 0.28 in patients with organic movement disorders, whereas Movement Disorders Clinical Practice for Review Only for the SC sign was 0.69 in both groups. CONCLUSIONS: The present study indicates that physicians must be cautious in the application and interpretation of these clinical signs in the diagnosis of functional movement disorders, and they should be carefully considered and used as necessary.

Reduced low-prevalence visual search detriment with increasing age: Implications for cognitive theories of aging and real-world search tasks.

When performing multiple successive visual searches, low-prevalence targets are at elevated risk of being missed. This has important implications for real-world visual search tasks, such as diagnostic medical imaging (e.g., searching for a cancer) and airport baggage security screening (e.g., searching for a weapon), which are characterized by low-prevalence targets and potentially dire consequences of target misses. Previous work on low-prevalence visual search indicates that individuals who spontaneously respond more slowly miss fewer targets, which has been attributed to higher quitting thresholds predicting better performance. Previous aging research indicates that older adults typically respond more slowly across multiple task contexts. This has been attributed to both intrinsic limitations in processing speed and a strategic trade-off to prioritize accuracy with increasing age. Synthesizing these two separate lines of research, here we tested whether older adults had a higher quitting threshold and/or slower processing speed in low-prevalence visual search, and the consequences of these for the magnitude of the low-prevalence visual search detriment. We recruited a large sample (N = 380) across a range of ages (20-80 years) and had them search for targets under low- and high-prevalence conditions. Older adults had both slower processing speed and higher quitting thresholds. Older adults were moderately less susceptible to the low-prevalence detriment, and this relationship was mediated by countervailing effects: slower processing speed exacerbated older adults' low-prevalence detriment, whereas elevated quitting threshold mitigated it. Theoretical implications for cognitive aging and practical implications for professional visual search tasks are discussed.

Four best-practice recommendations for improving the conceptualization and operationalization of motivational intensity: Reply to Kaczmarek and Harmon-Jones.

Replies to the comments made by Kaczmarek and Harmon-Jones (see record 2024-44184-002) on the current authors original article (see record 2021-21096-001). Kaczmarek and Harmon-Jones (2023) provide a commentary on our original empirical piece, does motivational intensity exist distinct from valence and arousal? (Campbell et al., 2021). In this response, we articulate the motivation behind our work, including the major issues with the conceptualization and operationalization of motivational intensity in prior literature. For example, while motivational intensity was proposed to replace valence as the determinant of cognitive scope more than a decade and a half ago, in both this original work and ongoing work since then, motivational intensity has been operationalized in a variety of questionable ways, including via participants' ratings of valence, rather than motivational intensity. That is, in multiple studies, differences in cognitive processes measured in two conditions have been attributed to motivational intensity which was not explicitly measured, while the conditions do demonstrably differ in the valence participants experienced. We explain exactly what we found in Campbell et al. (2021) and our subsequent follow-up work (Campbell et al., 2023), and what aspects of our interpretation converge versus diverge with the views offered in Kaczmarek and Harmon-Jones' commentary. We also identify four important recommendations for best-practice research going forward. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Unravelling the influence of affective stimulation on functional neurological symptoms: a pilot experiment examining potential mechanisms.

BACKGROUND: Differences in affective processing have previously been shown in functional neurological disorder (FND); however, the mechanistic relevance is uncertain. We tested the hypotheses that highly arousing affective stimulation would result in elevated subjective functional neurological symptoms (FNS), and this would be associated with elevated autonomic reactivity. The possible influence of cognitive detachment was also explored. METHOD: Individuals diagnosed with FND (motor symptoms/seizures; n=14) and healthy controls (n=14) viewed Positive, Negative and Neutral images in blocks, while passively observing the stimuli ('Watch') or detaching themselves ('Distance'). The FND group rated their primary FNS, and all participants rated subjective physical (arousal, pain, fatigue) and psychological states (positive/negative affect, dissociation), immediately after each block. Skin conductance (SC) and heart rate (HR) were monitored continuously. RESULTS: FNS ratings were higher after Negative compared with Positive and Neutral blocks in the FND group (p=0.002, ηp 2=0.386); however, this effect was diminished in the Distance condition relative to the Watch condition (p=0.018, ηp 2=0.267). SC and/or HR correlated with FNS ratings in the Negative-Watch and Neutral-Distance conditions (r values=0.527-0.672, p values=0.006-0.035). The groups did not differ in subjective affect or perceived arousal (p values=0.541-0.919, ηp 2=<0.001-0.015). CONCLUSIONS: Emotionally significant events may exert an influence on FNS which is related to autonomic activation rather than altered subjective affect or perceived arousal. This influence may be modulated by cognitive detachment. Further work is needed to determine the relevance and neural bases of these processes in specific FND phenotypes.

An updating-based working memory load alters the dynamics of eye movements but not their spatial extent during free viewing of natural scenes.

The relationship between spatial deployments of attention and working memory load is an important topic of study, with clear implications for real-world tasks such as driving. Previous research has generally shown that attentional breadth broadens under higher load, while exploratory eye-movement behaviour also appears to change with increasing load. However, relatively little research has compared the effects of working memory load on different kinds of spatial deployment, especially in conditions that require updating of the contents of working memory rather than simple retrieval. The present study undertook such a comparison by measuring participants' attentional breadth (via an undirected Navon task) and their exploratory eye-movement behaviour (a free-viewing recall task) under low and high updating working memory loads. While spatial aspects of task performance (attentional breadth, and peripheral extent of image exploration in the free-viewing task) were unaffected by the load manipulation, the exploratory dynamics of the free-viewing task (including fixation durations and scan-path lengths) changed under increasing load. These findings suggest that temporal dynamics, rather than the spatial extent of exploration, are the primary mechanism affected by working memory load during the spatial deployment of attention. Further, individual differences in exploratory behaviour were observed on the free-viewing task: all metrics were highly correlated across working memory load blocks. These findings suggest a need for further investigation of individual differences in eye-movement behaviour; potential factors associated with these individual differences, including working memory capacity and persistence versus flexibility orientations, are discussed.

Depression Moderates the Relationship between Trait Anxiety, Worry and Attentional Control in Melanoma Survivors.

Cancer survivors commonly contend with concurrent cognitive difficulties such as problems with attention and concentration, and psychological distress, including anxiety and depression. However, the associations between attentional and emotional difficulties within the specific context of melanoma survivors remain relatively unexplored. Premised on attentional control theory, the current study employed a cross-sectional design to explore the interplay among trait anxiety (dispositional) and situational anxiety (cancer-related worry), depression and attentional control (ability to inhibit distractors and flexibly shift within and between tasks) in a sample of 187 melanoma survivors aged 18 to 58 years (Mage = 36.83 years, SDage = 5.44 years; 93% female). Data were analyzed using a moderated multiple regression, with anxiety, cancer worry and depression as predictors, and attentional control as the criterion variable. After statistically controlling for the variance of chemotherapy, we found that individuals with higher trait anxiety and higher cancer-related worry reported greater attentional control at low levels of depression, yet poorer attentional control at high depression, relative to individuals with low anxiety. Our findings suggest that anxiety and depression are differentially related to attentional control in melanoma survivors. The results provide a marker for clinicians addressing anxiety and depression in this population. Implications for primary healthcare are discussed.

Sleepiness and comorbid sleep disorders in functional motor disorders: a comparative study with central hypersomnia.

Sleep symptoms, including excessive sleepiness, are frequently reported by patients with functional motor disorders (FMD). We aimed to classify the comorbid sleep disorders in FMD, and to investigate the relationship between subjective sleepiness and objective measures of hypersomnia, comparing them with data from people with central hypersomnia. A total of 37 patients (mean [SD] age 46.4 [11.2] years) with clinically definite FMD, and 17 patients (mean [SD] age 41.1 [11.6] years) with central hypersomnia underwent structured medical and sleep history, neurological examination, polysomnography, multiple sleep latency test (MSLT), and questionnaires assessing sleepiness, fatigue, and depression. In all, 23 patients with FMD (62%) reported excessive daytime sleepiness. Evidence of specific sleep disorders was identified in our cohort, with 35% having restless legs syndrome; 49% obstructive sleep apnea; and 8% periodic limb movements in sleep; however, the presence of these disorders was not correlated with subjective sleepiness. Patients with FMD with self-reported sleepiness reported higher fatigue (p = 0.002), depression (p = 0.002), and had longer sleep latencies in the MSLT (p < 0.001) compared to the patients with central hypersomnia. No correlation was found between subjective and objective sleepiness in either group. Fatigue positively correlated with self-reported sleepiness in patients with FMD (p < 0.001). This study did not find objective correlates of increased sleepiness in patients with FMD. While sleep abnormalities were found to be common in FMD, they were not correlated with self-reports of excessive sleepiness. Positive correlations between self-reported sleepiness and fatigue support the current unified model of non-motor symptoms in FMD.