[ F U N C T I O N A L ]

I retired as a doctor 2 years ago. My career was in psychiatry for older adults and I succesfully campaigned for a Timely approach to the diagnosis of dementia. I was concerned that an incentivised, target-based approach for early diagnosis, would result in unnecessary harm. The primary difficulty being that the neuro-pathological pathways to dementia were still not sufficiently understood to make accurate early diagnosis. Furthermore the various terms that had been used to describe mild-impairments of memory and other cognitive processes lacked in predictive value.

Since I have retired a whole new area of research has opened up under the rubric “Functional Disorders”. It seems to me, despite the lack in a clear understanding of this generalised [and reductive term], that it is being zealously introduced into the clinical domain.  This, at best, seems premature to me. There is huge momentum behind this ‘FUNCTIONAL’ rubric, and it is being  widely funded by government and industry.

“Functional Cognitive Disorder” seems to be replacing the term ‘Mild Cognitive Impairment’. This is a very difficult and complicated area which is full of uncertainties. My concern is that there are just as many uncertainties with  “Functional Cognitive Disorder” as with the old ‘label’, and that these uncertainties are not being fully shared with patients. Furthermore, it is likely that a subtle, but important shift, will result from this new terminology. What I mean is that the word “functional” places the onus on the patient and that this may allow professionals to re-attribute responsibility, and thus skew any balance of understanding.

This whole ‘FUNCTIONAL business’, has, in my opinion, become something of a ‘cult’. I am very much reminded of Improvement Science which I did my best to raise concerns about.

I am also troubled that those who are promoting this new diagnostic rubric have chosen NOT to include iatrogenic causes of ‘Functional Disorder’ – such as medicines taken as prescribed. I find this decision unscientific, unethical and mystifying [In delirium research, for example, iatrogenic aetiologies are essential considerations].

The following paper was recently widely shared by a leading and influential expert in dementia. It was shared without any acknowledgement of a wide range of uncertainties [some of which I have highlighted in yellow]:

6 Replies to “[ F U N C T I O N A L ]”

  1. I think you are indeed correct about the responsibility for ‘functional’ disorders passing to the patient. You should perhaps take a look at this -https://fundingawards.nihr.ac.uk/award/NIHR202743. It seems that ACT is being proposed as a potential treatment or therapy for ‘functional cognitive disorder’ (FCD), what used to be known as ‘mild cognitive impairment’, or ‘MCI’, I believe. Some years ago, I was diagnosed with the latter myself by a psychiatrist who was clear that it was simply an indication of cognitive ability at that time and could potentially get worse but could also improve, depending on the (unknown) cause. That was fine by me, I found it helpful since I suppose I was looking for some medical recognition that I had a problem, and things have improved a lot since then without any therapy or drugs. My gut feeling is that my problems were due to drug side effects which have lessened considerably over time. I did not need ACT for that recovery, I just needed recognition/to be believed and time and space to recover. I actually quite liked the old term ‘MCI’ because, if anything, to me it understated the amount of impairment I felt, and I’d have hated any exaggeration. I’d find ‘disorder’ insulting – it felt like my brain was ‘impaired’, not ‘disordered’ – and ‘functional’, don’t get me started on ‘functional’! I didn’t need to accept anything or commit to anything to improve, so why waste precious NHS money on pointless therapy? I’d already accepted that I was stuck with the problem for the time being, it was getting other people to accept that I had a problem that was the issue. Disappointingly, the MCI diagnosis didn’t make much difference to that, only to me, but I’m pretty sure that I wouldn’t have fared any better with a FCD label.

    1. Dear Liz,
      Thank you for this reply and for kindly sharing your experience.

      Having been retired now for over 2 years I am not as up-to-date as perhaps I once was.

      In relation to “Functional Cognitive Disorder” I am concerned that:
      [1] Responsibility for the ‘disorder’ is passed to the patient
      [2] Natural effects of ageing [and we all age] may be labelled as a ‘disorder’
      [3] Iatrogenic causes, such as psychotropic drugs – which are mass prescribed: will be ‘overlooked’
      [4] If there is underlying neurodegeneration, that this is missed.

      aye Peter Gordon

  2. Thanks to Liz W I have incorporated information in relation to “Acceptance and Commitment Therapy” [ACT] and the award of funding for a ‘Feasability Study’

  3. Here is a poem. just written:

    ACT

    My Paroxetine tablets [film-coated] have ‘felt’ “pill-shamed”.
    Academics have suggested that my tablets attend
    for a course of:
    ‘Acceptance and Commitment Therapy’.
    Academics, pills or patients: who is acting here?

  4. Thanks Peter.

    With respect to your 4 points and my MCI diagnosis, i.e. the older terminology, I didn’t feel at all that responsibility for the disorder had been passed to me but felt that at last someone was taking me seriously and was not disregarding what I was experiencing. I felt that my impairment was over and above what would be normal for the ageing process (and for typical post-menopausal memory problems/lapses), and the psychiatrist thought this as well. I thought (and hoped) that the possible/likely cause was drugs (not psychotropic ones in my case but ones which had caused neurological symptoms), but the psychiatrist noted abnormalities on my brain scan and stressed that IF my condition worsened, which it probably wouldn’t, that I should go back – i.e he was keen not to miss any possible underlying neurodegeneration. I was reassured and relieved to be believed.

    I appreciate that not all psychiatrists or doctors assessing and diagnosing ‘MCI’ might have been as good as the one I saw, but I was pleased that I went and was happy with the diagnosis. If all consultants were taught to explain MCI properly to patients, and not leave them with the impression that they are on a hopeless downward trajectory towards dementia, then I don’t think there would be any need for a change of terminology or approach. To my mind, a move to FCD would be a disaster for patients and a complete waste of money.

    1. Thanks Liz for sharing your experience. All that you share is natural, understandable and common sense.

      The approach that your specialist took was the same approach that I tried to take.

      In chatting to my wife this morning [Sian is a GP], I said very much the same as you: “If all consultants were taught to explain MCI properly to patients, and not leave them with the impression that they are on a hopeless downward trajectory towards dementia, then I don’t think there would be any need for a change of terminology or approach.”

      aye Peter

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