Introduction
Although many psychologists frequently assess, treat, and advocate for patients who have cognitive difficulties, one highly prevalent condition for which most clinicians receive little training is functional cognitive disorder (FCD). FCD is diagnosed when the patient has self-reported cognitive problems that are causing distress/disability in everyday life and are associated with internal inconsistency (Ball et al., 2020), a positive diagnostic sign. In this context, internal inconsistency refers to intact cognitive functioning within a particular domain (e.g., memory) in certain situations, with deficits in that same ability in other situations, particularly when the patient’s attention is focused on the problem. This is distinct relative to temporal fluctuations secondary to delirium, dementia with Lewy bodies, and circadian rhythms (e.g., “sundowning”). An example of internal inconsistency in FCD is a patient who experiences amnestic episodes (e.g., forgetting their home address) but provides a detailed account of memory impairments during a clinical encounter. Importantly, internal inconsistency in FND is distinct from feigning (Edwards et al., 2023) and instead reflects genuinely experienced symptoms that have neurobiological underpinnings (Drane et al., 2021).
Clinical Characterization
In contemporary taxonomies, FCD is considered to be a subtype of functional neurological disorder (FND), which has various manifestations such as seizures, motor abnormalities, and sensory disturbances, among others (Hallett et al., 2022). Importantly, FND is highly prevalent in neurology/psychiatry and FCD is estimated to be present in approximately one quarter of referrals to specialty memory centers (McWhirter et al., 2020). Although specific prevalence rates in psychology settings have not been investigated, it is reasonable to hypothesize that many psychologists frequently provide care to patients with FCD, particularly given the strong overlap between FND/FCD and mental health conditions such as depression/anxiety, PTSD, and somatization (Lloyd et al., 2022).
With growing recognition of FCD in neurology and neuropsychology, there has been increasing interest in differentiating it from neurodegenerative diseases (Cabreira et al., 2023). Compared to patients with common dementias, those with FCD have the following characteristics (on average): younger age, more years of education, unstable longitudinal course, more concern about their cognition than a collateral source, and the potential for intact working memory during clinical interactions. Moreover, FCD is likely relevant in the context of other neuromedical disorders such as long COVID, persistent symptoms after concussion, and chronic pain/fatigue (Teodoro et al., 2018). Thus, FCD can be thought of as a nexus that connects with multiple disorders in neuropsychiatry, making it an important component of many psychologists’ clinical work.
Beyond binary diagnostic decisions, assessing and treating FCD involves a deep understanding of hypothesized mechanisms and associated features of the disorder. Central to many patients’ lived experiences are their perceptions, predictions, and emotions related to their own cognitive functioning. In other words, cognitive lapses are frequently noticed and cause immense distress and suffering for these patients. Thus, FCD is much more than simply being “worried well” (Van Patten et al., 2025) and typically involves severe, persistent preoccupation with and rumination about current or future brain disease. This is reflected in the nocebo effect (Fiorio et al., 2022) in which strongly held beliefs and expectations for cognitive dysfunction can lead to hypervigilance and hyperfocusing on everyday lapses, reinforcing negative schemas such as “I’m stupid,” or “my brain is broken.”
A common patient story occurs when an at-risk person experiences a life stressor such as a car accident/concussion, a parent with dementia, or a COVID-19 infection. Although any direct physical sequelae may resolve, the person begins attributing daily mistakes to a presumed brain disorder and/or they discount the cognitive impacts of other factors such as poor sleep and low mood. This can evolve into a vicious cycle, manifesting as distress, cogniphobia, withdrawal from typical activities, self-critical thoughts, and increasing disability, solidifying the belief that cognitive problems result from a precipitating event (e.g., concussion) or portend future impairments (e.g., Alzheimer’s disease).
Biopsychosocial Evaluation and Treatment
A useful approach to clinical formulations in patients with FCD involves identifying predisposing, precipitating, perpetuating, and protective factors within a biopsychosocial framework (Fobian & Elliott, 2019; Silverberg & Rush, 2024). The primary tools for this formulation are clinical history, interview, and behavioral observations, supplemented by instruments such as the Multifactorial Memory Questionnaire (Troyer & Rich, 2002) and other questionnaires. The psychologist begins by attending to the patient’s history and ongoing symptoms, documenting longstanding vulnerabilities that may have predisposed them to FCD such as adverse childhood experiences, illness beliefs, or chronic depression. The clinician also notes potential precipitating events (e.g., head injury, death of a loved one) that may have triggered the onset of FCD. Lastly, perpetuating factors (barriers to healing/recovery) and protective (resilience) factors are detailed, given their potential roles in treatment.
Following the assessment phase, the individualized conceptualization is shared with the patient, presented as hypotheses that are open to discussion. This is typically accompanied by a conversation about the diagnosis of FCD in which the patient is invited to share their reactions and opinions, potentially leading to revisions to the formulation. Benefits of this approach for the patient can include improved insight and understanding about the biopsychosocial nature of FCD, relief at the validation of the authenticity of their symptoms, and direct implications for treatment planning. For example, in a 52-year-old woman who was a caretaker for her recently deceased father with dementia due to Alzheimer’s disease, perpetuating factors may include the belief that she is destined to develop Alzheimer’s disease herself, adoption of the sick role following her father’s death, and avoidance of relying on her short-term memory in everyday life. Meanwhile, protective factors could include a supportive spouse and high motivation for treatment. The intervention could be acceptance and commitment therapy, focusing on mindfulness, cognitive defusion, and small behavioral experiments to test out her memory in daily life. Her family members may be included in some of the sessions and she could focus on leaning on them for support during bereavement for her father.
Several research groups are working on developing and examining formal interventions for FCD, including Acceptance and Commitment Therapy for FCD (Poole et al., 2025), a multimodal Neurobehavioral Therapy (Cotton et al., 2024), and a self-guided mobile app intervention called Mementum (Cabreira et al., 2025). Although distinct, these approaches share concepts such as validation of the authenticity of FCD symptoms, insight building with regard to the potential for improved cognitive functioning, and the introduction of tools for coping with difficult thoughts and emotions. Work on clinical trials examining efficacy and effectiveness is ongoing and none of the treatments have yet been widely disseminated for clinical use. In the meantime, psychologists can rely on published guidance for care of patients with FCD (Silverberg & Rush, 2024; Van Patten & Keatley, 2025). When treatment is indicated, providers who have experience with FND and somatic symptom disorders are likely be well equipped to work with patients with FCD, given etiological and symptomatic overlap (Teodoro et al., 2018). Psychologists may also offer to connect patients with organizations offering education, support groups, and connections to care providers, including: https://www.fndsociety.org/, https://neurosymptoms.org/en/, and https://fndhope.org/.
A Note on Diagnosis
The presence of FCD features does not warrant a diagnosis in every case (Van Patten, 2026). There is already an overdiagnosis problem in some areas of mental health (O’Sullivan, 2025) and adding one more entry to a patient’s problem list does not necessarily help them or their family. In FCD, it is recommended that the diagnosis be made when functional cognitive symptoms are believed to be a primary cause/driver of the patient’s distress but not if other disorders (e.g., PTSD, chronic pain) are central. That is, if the psychologist’s biopsychosocial formulation results in the hypothesis that evidence-based treatments for other conditions will lead to downstream improvements in functional cognitive symptoms, then they should consider withholding the FCD diagnosis and focusing on alternative priority areas. Later on, if the alternative treatments do not improve FCD symptoms, the diagnosis can be made in order to provide a pathway to education and treatment. On the other hand, if the patient’s symptoms appear to emanate from FCD – e.g., insomnia and low mood secondary to frequent worry about brain damage and cognitive dysfunction – then diagnosing and formulating around FCD is likely to be the best course of action. This approach can reduce diagnostic uncertainty and lead patients to be connected with developing appropriate treatments.
Conclusion
FCD has been called “dementia’s blind spot” (Ball et al., 2020) and likely reflects an area of growth in the training of many healthcare providers, including psychologists. This article has discussed foundational concepts in the understanding, recognition, evaluation, and treatment of patients with FCD. Future research should examine longitudinal trajectories of FCD, how it may function as a prodrome to neurodegenerative diseases, and its role in common neuromedical conditions such as fibromyalgia and long COVID. With improved awareness, psychologists will be better equipped to provide care to many people with unexplained cognitive symptoms who are suffering a great deal but who have fallen through the cracks of the medical system.
References
Ball, H. A., McWhirter, L., Ballard, C., Bhome, R., Blackburn, D. J., Edwards, M. J., Fleming, S. M., Fox, N. C., Howard, R., Huntley, J., Isaacs, J. D., Larner, A. J., Nicholson, T. R., Pennington, C. M., Poole, N., Price, G., Price, J. P., Reuber, M., Ritchie, C., … Carson, A. J. (2020). Functional cognitive disorder: Dementia’s blind spot. Brain, 143(10), 2895–2903. https://doi.org/10.1093/brain/awaa224
Cabreira, V., Frostholm, L., McWhirter, L., Stone, J., & Carson, A. (2023). Clinical signs in functional cognitive disorders: A systematic review and diagnostic meta-analysis. Journal of Psychosomatic Research, 173, 111447. https://doi.org/10.1016/j.jpsychores.2023.111447
Cabreira, V., Frostholm, L., Stone, J., & Carson, A. (2025). Development of a self-help digital intervention for functional cognitive disorder: A theory- and user-centred approach (Preprint). https://doi.org/10.2196/preprints.76263
Cotton, E., Mordecai, K. L., McWhirter, L., Cabreira, V., Van Patten, R., Silverberg, N. D., Kaat, A. J., & LaFrance, W. C. (2024). Taking Control of Your Functional Cognitive Symptoms Workbook: A Novel Intervention. Psychiatry and Clinical Psychology. https://doi.org/10.1101/2024.10.15.24315532
Drane, D. L., Fani, N., Hallett, M., Khalsa, S. S., Perez, D. L., & Roberts, N. A. (2021). A framework for understanding the pathophysiology of functional neurological disorder. CNS Spectrums, 26(6), 555–561. https://doi.org/10.1017/S1092852920001789
Edwards, M. J., Yogarajah, M., & Stone, J. (2023). Why functional neurological disorder is not feigning or malingering. Nature Reviews Neurology, 19(4), 246–256. https://doi.org/10.1038/s41582-022-00765-z
Fiorio, M., Braga, M., Marotta, A., Villa-Sánchez, B., Edwards, M. J., Tinazzi, M., & Barbiani, D. (2022). Functional neurological disorder and placebo and nocebo effects: Shared mechanisms. Nature Reviews Neurology, 18(10), 624–635. https://doi.org/10.1038/s41582-022-00711-z
Fobian, A. D., & Elliott, L. (2019). A review of functional neurological symptom disorder etiology and the integrated etiological summary model. Journal of Psychiatry & Neuroscience, 44(1), 8–18. https://doi.org/10.1503/jpn.170190
Hallett, M., Aybek, S., Dworetzky, B. A., McWhirter, L., Staab, J. P., & Stone, J. (2022). Functional neurological disorder: New subtypes and shared mechanisms. The Lancet Neurology, 21(6), 537–550. https://doi.org/10.1016/S1474-4422(21)00422-1
Lloyd, M., Winton-Brown, T. T., Hew, A., Rayner, G., Foster, E., Rychkova, M., Ali, R., Velakoulis, D., O’Brien, T. J., Kwan, P., & Malpas, C. B. (2022). Multidimensional psychopathological profile differences between patients with psychogenic nonepileptic seizures and epileptic seizure disorders. Epilepsy & Behavior, 135, 108878. https://doi.org/10.1016/j.yebeh.2022.108878
McWhirter, L., Ritchie, C., Stone, J., & Carson, A. (2020). Functional cognitive disorders: A systematic review. The Lancet Psychiatry, 7(2), 191–207. https://doi.org/10.1016/S2215-0366(19)30405-5
O’Sullivan, S. (2025). The Age of Diagnosis: How Our Obsession with Medical Labels is Making Us Sicker. Penguin Random House. https://doi.org/10.1007/s10912-025-09984-z
Poole, N. A., Cope, S., Vanzan, S., Duffus, A., Williams, T., Mantovani, N., Smith, J. G., Barrett, B., Scicluna, M., Beardmore, S., Edwards, M. J., & Howard, R. (2025). Randomised controlled feasibility trial of online group acceptance and commitment therapy for functional cognitive disorder. BJPsych Open, 11(3), e91. https://doi.org/10.1192/bjo.2025.33
Silverberg, N. D., & Rush, B. K. (2024). Neuropsychological evaluation of functional cognitive disorder: A narrative review. The Clinical Neuropsychologist, 38(2), 302–325. https://doi.org/10.1080/13854046.2023.2228527
Teodoro, T., Edwards, M. J., & Isaacs, J. D. (2018). A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: Systematic review. Journal of Neurology, Neurosurgery & Psychiatry, 89(12), 1308–1319. https://doi.org/10.1136/jnnp-2017-317823
Troyer, A. K., & Rich, J. B. (2002). Psychometric Properties of a New Metamemory Questionnaire for Older Adults. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 57(1), P19–P27. https://doi.org/10.1093/geronb/57.1.P19
Van Patten, R. (2026). Recommendations for Refining the Diagnosis of Functional Cognitive Disorder. Journal of Neuropsychiatry and Clinical Neurosciences. https://doi.org/https://doi.org/10.1176/appi.neuropsych.20250279
Van Patten, R., & Keatley, E. (2025). Cognitive Rehabilitation for Functional Neurological Disorder. CNS Spectrums. https://doi.org/https://doi.org/10.1017/S1092852925100825
Van Patten, R., Mulhauser, K., Austin, T. A., Bellone, J. A., Cotton, E., Chan, L., Twamley, E. W., Sawyer, K., & LaFrance, W. C. (2025). The association between subjective and objective cognitive functioning from a transdiagnostic perspective: An umbrella review and meta-analysis. Clinical Psychology Review, 121, 102648. https://doi.org/10.1016/j.cpr.2025.102648
Ryan Van Patten, PhD, ABPP
Correspondence: ryan_van_patten@brown.edu