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A psychological perspective

Approaches to treating functional cognitive symptoms

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Neuropsychological assessment

The basis of a multidisciplinary treatment plan is a comprehensive neuropsychological assessment, including:

  • History and timeline of cognitive symptoms

  • Nature and type of symptoms

  • The impact of cognitive symptoms on important aspects of life

  • Potential organic causes of symptoms

  • Impact of potential psychological causes of symptoms (e.g. depression, anxiety)

  • Development history

  • Reports of symptoms from relatives or close people

Normalisation of cognitive symptoms

Try to normalise cognitive lapses in a healthy population (e.g. we all have those times when we can't find our keys, when we can't remember what we wanted to take out of a room we walked into, when we can't remember where we parked the car in a huge and crowded car park).

In addition, it is good to confirm to patients that their symptoms are real and that they can cause severe distress, anxiety and interfere with daily functioning. It is important that patients do not get the feeling that we think they are faking or simulating their symptoms.

Psychoeducation

In addition to using the PC model, it is useful to use other strategies and techniques to explain the nature and function of the patient's symptoms. We can explain to the patient in a sympathetic way:

  • Discrepancies and variability between results on different standardised tests

  • Discrepancies between results and daily functioning

  • Discrepancies between performance and doing work that requires high cognitive abilities

  • Fluctuations in cognitive symptoms in response to stress and emotion

  • Secondary beliefs about memory (e.g. memory problems trigger worry and/or anxiety that is in addition to the original source of worry)

  • How symptom onset and fluctuation differ from other neurodegenerative disorders (e.g. sudden and gradual onset of symptoms)

  • Normalisation of cognitive errors (e.g. everyone has entered a room with the intention of doing something, but then forgot what their intention was)

The therapeutic relationship

A safe therapeutic relationship is the key to successful treatment, although it is sometimes impossible to devote so much time to it because of the large number of patients you have on a daily basis. Nevertheless, it is worth making the effort and showing Rogers' qualities such as authenticity, unconditional acceptance and empathy.

Behavioural techniques

Behavioural techniques can be useful in challenging and rejecting unhelpful beliefs about cognitive lapses and tolerating stress while not placing as much emphasis on cognitive success:

  • The patient can be given the task of asking people in their immediate environment what their most common cognitive errors are and what importance they attach to them - or do they catastrophise too?

  • What is the worst thing that can happen if I forget x thing?

  • Joining new social activities where the patient satisfies the need for social belonging while testing beliefs about cognitive errors

  • Memory diary (consistent recording of memory 'errors' can help the patient to see how cognitive functioning is affected by emotions, thoughts, stressful periods in life, medication, sleep deprivation, dehydration, fatigue, etc.)

Cognitive rehabilitation

Cognitive rehabilitation is primarily used for organic cognitive impairment, but in some cases it can also be useful for patients with functional cognitive impairment, especially if their symptoms severely interfere with their daily functioning. Care must be taken not to reinforce their role as a patient, as this will lead them to rely too heavily on cognitive techniques, even though, at least in theory, their problems are reversible.

Using the PC model to treat cognitive symptoms

  • Excessive focus on symptoms.

  • Social isolation, deficit in testing beliefs about cognitive defects, systematic re-tramatisation.

  • Inability to express emotions in a safe environment and/or relationship.

  • Personal triggers.

  • The impact of medication, sleep deprivation, pain, poor diet, dehydration and fatigue on functional cognitive symptoms.

  • A de-regulated valve, leading to fatigue and consequent cognitive dysfunction.

  • Strong emotions and negative beliefs, which can lead to dissociation due to the unpleasantness of these states.

  • Use of memory suppression and/or dissociative amnesia.

    • Ball, H. A., McWhirter, L., Ballard, C., Bhome, R., Blackburn, D. J., Edwards, M. J., ... and Carson, A. J. (2020). Functional cognitive disorder: dementia's blind spot. Brain, 143(10), 2895-2903.

    • van der Hulst, E. J. (2023). A Clinician's Guide to Functional Neurological Disorder: A Practical Neuropsychological Approach. Routledge.