Dr. Jeremy Sharp (00:00.568)
Hello everyone and welcome to the Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I just keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com slash therapy notes and enter the code testing. This episode is brought to you by PAR.
The new PAR training platform is now available and is the new home for PAR talks, webinars, well as on-demand learning and product training. Learn more at parinc.com backslash resources backslash par dash training.
Hey, folks, welcome back to the podcast. I am happy to be here with you. Today’s topic is fascinating. We’re talking about functional neurological disorders and primarily functional cognitive disorder with Dr. Ryan Van Patten. So you may recognize his name. He is a co-host of Navigating Neuropsychology. Ryan’s an assistant professor at Brown University and board certified clinical neuropsychologist at the Providence VA Medical Center in Providence, Rhode Island.
He’s an active researcher, clinician, and educator. As an early career clinical scientist, he has over 60 peer-reviewed publications, more than 30 of those are first authored. That is incredibly impressive. As well as VA grants, book chapters, and editorial service. His research program focuses on functional neurological disorder, digital neuropsychology, traumatic brain injury, and cognitive rehab.
Dr. Jeremy Sharp (01:48.15)
So his contributions to education and training include the role as the co-founder, co-producer, and co-host of Navigating Neuropsychology podcast, role as a member of the board of directors for the American Academy of Neuropsychology, and his position as neuropsychology track coordinator for the clinical psych internship program at Brown. So Ryan does a lot. I am super impressed with him. And as we talk about, you know, there’s not many folks in the
testing podcast world. it’s always nice to hang with him and chat about testing stuff. So as far as the topics of conversation, this is, like I said, fascinating. I think a lot of us have seen some of these cases of functional neurological disorder, what used to be called conversion disorder. So we do a lot of background. We do some definitions of what it is, the different subtypes focusing specifically on functional cognitive disorder.
We talk about how to differentiate it from more common concerns, I suppose, like cognitive impairment, early dementia, talk about distinguishing factors. We talk about, of course, how to test or assess this concern and how the assessment process differs from maybe other disorders or concerns that we would look at. We talk about how to explain
a functional neurological disorder diagnosis to patients, which I think is very important to walk the line between validating and not exacerbating. Talk about treatment, of course, and then we talk about future directions. So there’s a ton to take away from this conversation. Ryan is incredibly knowledgeable, and I feel very fortunate to have him on the podcast today. So I’ll let you enjoy my conversation with Dr. Ryan Van Patten.
Dr. Jeremy Sharp (03:54.264)
Ryan, hey, welcome to the podcast.
Hey Jeremy, great to be here. Thanks for having me.
Yeah, absolutely. Good to cross paths with you again. You know, there’s not many of us here in this testing podcast world. So always glad to be on the same call with you. Yeah, right, right. Well, we’re talking about a topic I think that’s pretty hot in our field lately. And I’m glad to have you on to really dive into some of the details about functional neurological disorders and functional cognitive disorder and that kind of thing. So.
together.
Dr. Jeremy Sharp (04:25.176)
I’ll start with this question that I always start with, is, you of all the things you can spend your time and energy on, why do you care about this? Choose to present on this, choose to talk about it.
Yeah, it’s a good way to start. Appreciate the invite here and the question. If I reflect back on my training, even going back to college, but especially grad school through postdoc and early career, I’ve had a lot of different interests within clinical psychology and neuropsychology. I’ve spent time doing research in Alzheimer’s disease, Parkinson’s, traumatic brain injury, substance use, schizophrenia, kind of all over the board. There isn’t just one thing that interests me when we’re talking about the brain and
and psychological testing, there is a lot that I find fascinating. So I hovered around different areas. Working in those different domains, I questioned these, what I would consider artificial distinctions between neurology on the one hand and psychiatry on the other. know, neurological disorders, they tend to come with a lot of mental health symptoms, which sounds like psychiatry. And psychiatric disorders exist in the brain and have neural correlates, which sounds like neurology.
So I really started thinking about neuropsychiatry. And when I discovered and started to get into FND, functional neurological disorder, it became clear that it’s the quintessential neuropsychiatric disorder. Mind, brain, body, you can’t put it in a box. It doesn’t, it resists that. It doesn’t cleanly fit into any of our categories. The Cartesian dualism just doesn’t work. And so that was a really…
sort of center point of my interests and pursue it from there.
Dr. Jeremy Sharp (06:06.69)
Yeah, I love that. really does. It’s a little bit of an enigma in that sense. I I like that it crosses all these worlds. And if you care at all about understanding our brain and behavior, which I know you do and a lot of us do, it’s a nice little complex problem to dig into. Let’s see. So that might be a nice segue just to talk background for folks who may not be totally familiar with FND and then some of those subtypes. Let’s lay a little bit of background.
give us a sense of what it is, what we’re looking at.
Yep. So basic definition of functional neurological disorder, which I should say that is the umbrella term and then functional cognitive disorder is one of these subtypes underneath FND. So we’ll start broad. FND is a neurological neuropsychiatric disorder where there are cognitive sensory or motor symptoms that are due to dysfunction in neural networks rather than a focal neuroanatomical lesion. the
dysfunction in neural networks is where you get the F in FND. It’s not identifiable structural pathology like you might see on an individual basis on an MRI scan, but the neural circuits are impacted. This FND used to be called conversion disorder. Some people may have heard of that. The idea came from Freud with the idea of being that psychological distress, often from trauma, is transformed or somehow this mysterious process that’s converted from
the psychological distress into an outward physical symptom. And conversion disorder still holds some water today. know, mental health symptoms are common and very important in FND, but as we’ve researched it more, we’ve broadened to the biopsychosocial model to understand it more generally.
Dr. Jeremy Sharp (07:53.966)
Can you talk about that a bit? I think that’s something to focus on just to provide a little context, you know, the conceptualization of these disorders, and then we’ll dig into the whole conversion aspect. Is it real? Is it not real? You know, there’s a lot of questions around this. So, yeah, let’s start with the biopsychosocial component.
Yep, sounds great. So on the one hand, the model is fairly straightforward. Biocircosocial model is what it sounds like. It’s in contrast to the old biomedical model where diseases, illnesses were really viewed as purely biological in medicine for a time, at least in some circles, and especially the social, sociocultural piece was really devalued. So in contrast to that.
researcher George Engel came up with the biopsychosocial model to have three legs of the stool. We are very much appreciating that in this case, if we’re talking about mental health, neuropsychiatric disorders, there is a biological, physical component exists in the brain, very important. But there are two equally important components, different levels of the hierarchy that we need to pay attention to particularly.
clinically, psychological, which will be familiar to us as testing psychologists and neuropsychologists, and then social, sociocultural. It fits very well for FND, which as we talked about, you it doesn’t fit cleanly into any particular bin. So there’s a particular way to take the biopsychosocial model and start to translate it clinically to FND. I’m happy to talk about that now, the four P’s, if you’d like, or we can save that for later. What’s your preference?
Yeah, yeah, why don’t we go ahead and dive into that.
Dr. Ryan Van Patten (09:37.176)
Okay. So four P’s, which is how we take the biopsychosocial model and sort of bring it to life in terms of clinical practice. So I use this all the time in neuropsych evaluations or any, really could be therapy, really any clinical context with a patient. It doesn’t just apply to FND, but very useful. We can talk about how. So first P is predisposing factors, predisposing for the illness, in this case, FND. These are.
longstanding background risk factors that increase a person’s overall vulnerability developing the disorder. Genetics would fall into this camp, childhood, abuse, trauma, chronic illness. Again, within each of the P’s, could be bio or psychos or social or a combination of them. So predisposing longstanding vulnerability factors. Next is precipitating factors. These are
acute or subacute events that really you can think of them as a final straw. The last thing that sort of pushes a person over the edge to developing FND. So an acute event could be a concussion, it could be a surgery, could be death of a loved one, divorce or job loss, could be a vaccine. We’ll talk more about this, I’m sure. A lot of sort of expectation effects and emotional weight goes into that as the explanation for why I then have the symptoms.
And then third P is perpetuating factors. So at this point, our patient has developed FND and now these are factors that are stressors or other experiences that are barriers to healing and recovery. So social stigma is a big one. Unemployment, mental health symptoms, illness beliefs would be another one. These can be so critical for treatment to identify what are the perpetuating factors that are.
getting in the way and making it hard to make progress because you identify them, you target them, talk about them. Lastly, our protective factors. So far I’ve been talking primarily about these sort of risk or vulnerability factors, but on the flip side, protective factors are strengths, resilience that more mitigate the impact of FND and or, you know, if we think about the strengths of a person, these are aspects of that individual that help.
Dr. Ryan Van Patten (11:56.76)
promote better outcomes, healing and recovery. So we would take all those factors and make hypotheses for a patient. These are your predisposing factors, precipitating factors, et cetera, based on what I know about you after a full biopsychosocial evaluation. Be transparent, talk to the patient about it, see what they think. It’s okay if they disagree. It helps them understand the multifaceted nature of FND and it can really help treatment planning.
Yeah, I like that framework. I mean, I love a good framework anytime. Did that come out of the same biopsychosocial research or is that kind of a separate framework that was developed elsewhere just for our knowledge?
Yeah, I think of it as very much linked to the biopsychosocial model. It’s not the only way to use the biopsychosocial model, but it’s a way that takes, there’s a lot of research on biopsychosocial model. Some of it is more theoretical. It’s a framework, like you said, a model we’re developing and important to understand how health and illness work. And then there’s our patient in front of us. the four P’s to me help us sort of.
from the literature and the biopsychosocial model and then apply on an individual basis with our patients.
Sounds great. So I want to go back just a little bit and provide a little more background, suppose, particularly around the neurological component of this disorder or group of disorders. And I kind of alluded to this. I think there’s some question, you know, among some folks on our field around like the legitimacy of some of these presentations, right? And is it real? Is it not real? I’d be curious from the neurological standpoint, you said it’s not focal. This is not something we can necessarily pick up with.
Dr. Jeremy Sharp (13:35.106)
with imaging, what does the neural network model look like in these cases? I guess what I’m getting at here is like, is there anything we could actually see or pick up on from a neurological standpoint, or is this just one of those things where this is happening in multiple systems of the brain? So it goes and we can’t really pinpoint it.
Yeah, I love the question. And I’d like to say yes to both. So we can certainly pick up on it from a neurological standpoint in terms of clinical symptoms. I know you’re sort of also bringing in imaging here and the underlying neural networks, which is important. But the diagnosis is made in a patient based on clinical evaluation and positive diagnostic signs, which we can get into. From the standpoint of all of this neuro
biology and the pathophysiology of FND. There’s a lot of really great research going on. There are not good biomarkers right now. There’s not sort of, you go in for a resting state FMRI and this network is, default mode network is more activated, so you have FND. It’s not at that stage. But there are a variety of networks similar to research and depression and schizophrenia and other.
mental health conditions, networks like the Salience Network, the limbic system that are clearly involved in FMD. Some of the research now is more on, we know that patients with FMD have dysfunction in X network. As one example, patients with FMD tend to show high functional connectivity between emotion processing circuits like the limbic system and motor control regions like the central gyrus. And it’s fascinating that
could give us a little window or explanation into why negative affect like anxiety and stress can be a trigger for a functional neurologic symptom like a seizure. If there is sort of over connection or over activation, too much communication between the amygdala and our movement centers. that’s one example.
Dr. Jeremy Sharp (15:43.874)
Right, right. I might be getting out of my depth a little bit here, but that also makes me think of the connection. I mean, I feel like I’ve seen a lot of folks in this world who have tic disorders, you know, as the functional manifestation. So I don’t know if that’s too much of a leap for that connection as well.
Yeah, definitely not. You’re right in the money. Functional tic disorders are real and you might put them under functional movement disorders that subtype. There’s fascinating stuff that’s happened with that. TikTok, the social media platform, you know, spread some tics in adolescents and teens through symptom modeling and other mechanisms we can talk about. It’s definitely an issue.
Yes, yes, yes. Yeah, let’s talk a little bit more about some of the subtypes. So we said, you know, FND is the umbrella term mentioned, FCD as well, which I think we’ll talk a lot about, but just what are some of the other subtypes that we might see?
Yep. I would say for testing psychologists and neuropsychologists, the three subtypes you’re most likely to see would be functional cognitive disorder, functional seizures, often also goes by a number of names, psychogenic, non-apoleptic seizures, PNES, and others. So that’s two. A third one would be functional movement disorders, which are, there are many.
Tremor, dystonia, gait problems, tics, et cetera. I would say those are the three that have seizures and movement disorders have the biggest literature on them. And cognitive disorder is newer, but clearly very relevant to us, given that we do a lot of testing of cognitive functioning. There are other subtypes that are good to be aware of. There’s a dizziness subtype that goes by some mouthful. It goes by persistent, postural, perceptual dizziness, or sometimes called.
Dr. Ryan Van Patten (17:27.15)
Triple PD for short, so that is considered an FND. There are functional sensory disorders, blindness, and others, and a variety of others, but I’d say those are the big ones.
Sure, sure. There are so many manifestations. This is fascinating. This is fascinating how the body and brain do things to us.
Some people suggest or think that you could have FND that mimics any other neurological disorder, interestingly. So, you know, any symptoms somebody might have from a classic conventional neurological disorder or something you’ve heard about in a textbook could be quote unquote mimicked by an FND.
Well, let’s dive deeper into FCD. I think that’s the main topic of our conversation today. So, yeah, let’s zero in on that. Give me a definition and then we’ll go from there.
Sure. So this is a cognitive subtype of FND, although a good statement that I should make on the front end is that, as we’ve mentioned, these are not all clean, so you can have cognitive problems in other FND subtypes. It’s actually very common. Seizures, movement disorders, some studies suggest over 80 % of those folks have cognitive problems. But when we’re thinking about the sort of diagnosis of FCD, there’s a diagnostic criteria paper.
Dr. Ryan Van Patten (18:41.582)
that was published. I’m happy to share if you want to put it in your notes, show notes tab from 2020, Harriet Ball and others. And there’s a few pieces, few criteria. It’s actually cognitive disorders not on the DSM yet, although I think that’s coming. But so people know you must have cognitive problems, no surprise, which must cause impairment or distress and can’t be explained by any other medical or neuropsychiatric syndrome.
All of those probably sound familiar. The oddball is something called internal inconsistency for FCD. And the internal inconsistency is the positive diagnostic sign for FCD. That’s the part I’m guessing folks haven’t heard as much about. Happy to go into more detail on that if you want or. Okay. So internal inconsistency in this context would mean the ability to perform a cognitive task.
Yeah, yeah, please do.
Dr. Ryan Van Patten (19:39.842)
well at some times, but with impairments in that task at other times, especially when the task is the focus of attention. It’s not the same thing as cognitive fluctuations like you might see in delirium or sundowning or DLB. It’s different. Also goes by the name contrasting function and dysfunction. So would it help if I gave a few examples?
Yeah, yeah, for sure. I’m thinking of examples in my own life, mainly with my kids who seem to be able to, you know, brush their teeth at certain times and not others, but no, I’m joking. Yeah, give me some good examples here.
Yep. all right. Internal inconsistency, which is the same thing as contrasting function and dysfunction and is the core criterion we need to learn about for FCD. What this might look like is a patient, a person who reports having dense amnesia in everyday life, like major memory problems. They freeze up and can’t remember my social security number. I forgot my home address. I can’t…
I can’t remember anything. Often a lot of distress around that. That’s the dysfunction. And then the contrasting function would be during cognitive testing, maybe they score like in the low average to average range on memory testing, which is a discrepancy. It’s, you know, clearly, you know, it doesn’t have to be perfect scores throughout testing, but showing that you don’t have a severe classic amnestic deficit. that same person.
with all of the memory problems in everyday life. Another way you could find contrasting function and dysfunction is just observing how the clinical interview goes. So if they’re able to provide a relatively full and coherent narrative describing their memory failures, like, you know, doc, last week I went to the store and I was wearing my favorite blue shirt and somebody cut me off in traffic and I got there and I suddenly forgot what
Dr. Ryan Van Patten (21:35.148)
you know what two plus two is, and that’s a little exaggerated, but in the example, if they are really able to provide you with that full narrative, then that is telling you the, as giving you internal inconsistency.
Yeah, great example. One more example. quick, if it’s okay. Somebody has major word finding problems, dysnomia, you can easily observe. But I mentioned part of internal inconsistency is that it’s worse, the problems are worse when their attention is focused on the problem. Sometimes you can sort of titrate this when you’re talking to them. If you ask them about how’s your cognitive functioning, how are you doing remembering words?
Go f-
Dr. Ryan Van Patten (22:19.064)
problems, remembering words, their attention is focused on that issue and it usually gets worse. Then later, if you distract them about, you know, asking them about a hobby, a favorite pet, something that takes their mind away from the word finding problems, you would notice this isn’t always perfect, but you can, I’ve seen this many times, that even they might not be totally intact, but the word finding problems get better and they’re a little more fluent and they can describe it better.
That makes sense. Just intuitively, it seems like when people are relaxed or paying less attention to the thing that they’re worried about, you know, think about athletic performance and any number of other things, you know, social interactions, things like that. That does make intuitive sense. Are there other manifestations? So you mentioned memory issues, word finding. Are there other kind of classic presentations of FCD that we might see?
Great question. There are other types of symptoms that come up a lot. Brain fog would be one. I would say you would hear a lot about that. know, might be brain fog is a diffuse term. It doesn’t really link perfectly to our classic cognitive domains, but it might be more attention, executive functioning. can certainly come out in that domain. I’ve seen less of a, a fewer examples of like a discrete visuospatial
contrasting function and dysfunction. I think that would be less common, but theoretically you could see it in any cognitive domain. And there are many other, you know, we can talk about this as we move forward, many other ways it can manifest in patients, different sort of soft signs or pink flags you might see.
Right, right. Are there any discernible demographic factors here that, where it’s more likely to present?
Dr. Ryan Van Patten (24:06.594)
Yep. Yeah. So the most work in this area, it’s a very good question, would be comparing FCD to dementia or severe cognitive impairment due to neurodegenerative diseases. FCD, like other FNDs, is kind of a nexus. There’s a part of it that links to mild TBI. There’s a part that links to long COVID. This part that links to sort of Alzheimer’s disease and dementia. There’s a good systematic review, Veronica Cabrera, where she looked at…
comparing characteristics of people with cognitive impairment due to degenerative disease versus FCD and how they differ and found that people with FCD tend to be younger on average. So it varies, but broadly speaking, 40s, 50s, more so than people with Alzheimer’s disease, 60s, 70s, 80s. People with FCD tend to…
have higher levels of education. Again, it’s not a hard and fast rule, but the idea there is that having more education might lead some people to have a higher bar for themselves, perfectionism, a little more of a focus on their cognitive problems and they have trouble accepting normal memory failures that predisposes them. One other would be actually having a family history of dementia puts you at greater risk for FCD.
Make sense?
Dr. Ryan Van Patten (25:32.354)
presumably not because of a direct biological genetic link, but because of the experience of going through witnessing a family member who gets Alzheimer’s disease and declines and all of the distress and expectations and worry that, my mother had it, so I think I’m getting it, then can predispose somebody.
Right. Almost like a hypersensitivity to the potential symptoms. Yeah. Yeah. That makes sense. Yeah. It’s interesting. You mentioned, it’s like, you you’re reading my mind or vice versa, you know, I thought about, okay, long COVID and, you know, post-concussion stuff here. And I know those are both, we could really spin out into conversations about both of those, but I’m glad that you highlighted those and kind of validated, you know, I was thinking, oh, those are just like perfect, you know, scenarios that are ripe for this kind of.
presentation. Yeah. Nice. yeah, I think that’s a fantastic background and people should have a good idea of what we’re talking about here. So can you talk a little bit more about, you said the primary area that we’re maybe differentiating from is this mild cognitive impairment, dementia, that kind of thing.
Are there other factors that you might look at to go down that differentiation path? Like how is it standing out from true cognitive impairment?
Right, differentiating FCD versus MCI versus dementia, on the other hand.
Dr. Jeremy Sharp (27:04.587)
Right. Right.
Yeah, great question. So I think where I would start as we’re thinking about this would be, I always would come back to definitions. So we went over the definition of FCD with internal inconsistency in particular being that unique criterion. And then how that differs from, if you look at mild neurocognitive disorder and the DSM-5, mild neurocognitive disorder, which is essentially the same thing as MCI, requires a decline from a
prior level of functioning in terms of cognitive performance, preferably documented with standardized normed neuropsych testing. And FCD does not require that. We can get into cognitive testing in FCD. It’s certainly not that literature is growing and we need more work there. Unlike MCI, where we really want to our hat on these quote unquote objective.
criteria based on test scores, know, several scores, one to 1.5 standard deviations below the mean or more. In FCD, it’s that internal inconsistency we’re looking for. so I would say when you’re seeing a patient, you know, think about the two sets of criteria. People could have both. It’s possible to have both FCD and MCI. There’s sort of this misconception in some circles that FCD and FND must have
perfectly clean neuropsych and or labs and other test results. That’s just not the case. They could both be there, but just like you would do a differential anxiety and depression, you know, they’re sort of overlap, but it’s, you know, they’re also different and it can be helpful to differentiate them. I would take a similar approach. There’s also, there’s sort of other features of FCD that we can get into stuff like negative expectancies, abnormal Bayesian priors that
Dr. Ryan Van Patten (28:54.831)
sort of some of the mechanism, metacognition, that kind of thing that can help differentiate it if that’s where you want to go or we can save that for later.
Yeah, yeah, no, let’s talk about that. If for no other reason than I love the term abnormal Bayesian prior and just want to figure out what that’s what that’s all about. So yeah, let’s go that direction. Yeah.
I’m sure. So I bring that up because here we’re thinking about some of the mechanisms that underlie FCD. Like what are the characteristics of somebody, their vulnerability factors, this is all very biosecure social, things that are both in their head, but also that we can observe through their various symptoms as we’re formulating for them, like how can we explain FCD? So the…
term of the day, abnormal, and prior, maybe at times we like to use big words to make ourselves feel smart. It’s really not as complicated as it sounds. Essentially, this is a pre-existing expectation for cognitive impairments. So imagine somebody who has a concussion and then develops FCD afterwards. Concussion is a very common precipitating event that could lead to FCD. If they have a lot of messaging,
in a lot of thoughts and predictions and expectations about brain damage from concussion and chronic traumatic encephalopathy. And they’ve been exposed to a lot of news and social media. Maybe they’re an athlete. Even if not, they have a concussion from a brain injury standpoint. We might say it’s a mild concussion, mild TBI. No LLC, no loss of consciousness, no imaging findings. And we would expect
Dr. Ryan Van Patten (30:40.142)
that their brain will recover rapidly. But that’s, you know, that’s sort of a, that’s not the full biopsychosocial view of the situation because they are leading with all of the expectations. They have a concussion. If it’s a car accident or some other stressful event, all of that is swirling around. some people, some patients I’ve seen, then will tell you like after the concussion, I knew it, my brain was broken. Like I had a concussion and I just had to accept that I was disabled.
It’s this, you’re coming to the table with something. It’s a self-fulfilling prophecy of dysfunction that can really sort of come to fruition in their everyday life. Another term here that is good to know in the FND space is nocebo effects, the flip side of placebo. You know, if you get a placebo and you think you’ll get better and then you do get better because of the expectations, I think that’s great. Some people could have a nocebo where they believe, they anticipate
they will be disabled or impaired from something and the expectations sort of play out.
Yeah, yeah, I mean both huge influencing factors in this whole picture. I’m trying to hold back from how to talk with folks about this, so I’m gonna pin that. I think that’s super important. I definitely wanna dive into how you actually chat with folks about all of this and maybe combat some of those things. But yeah, this is helpful. mean, are there other metacognitive factors just to be aware of as we’re working with folks?
Yep. A few others that none of these are 100 % accurate. You might think of them as like said, soft signs or pink flags. You know, you put the whole picture together, the full formulation, but things that you’ll often see would be hypervigilance to cognitive problems. They’re anticipating them. They are, they are expecting them. Generally speaking, think about
Dr. Ryan Van Patten (32:39.948)
the idea of subjective cognitive concerns, subjective cognitive decline. This is a whole area of research related to Alzheimer’s disease and other degenerative diseases. FCD is essentially in the vast majority of people, if not everyone of FCD, it is very elevated subjective cognitive concerns. The person’s cognitive functioning tends to be a big deal for them. It’s on their mind. They might be convinced they have Alzheimer’s disease or convinced that because of
XYZ factors, their brain does not work anymore. And so if you’re a testing psychologist or a neuropsychologist, it is going to be common in your practice. You’ll see people who have concerns about their cognition, but this is sort of another level to that. Usually the person with FCD is more concerned about their own cognition than are their family and friends because they feel like I walked into a room and forgot why and my God, that means that I have dementia. And it’s not just that thought.
it’s sort of a schema and it becomes rigid for them and there’s a lot of anxiety and distress around it. They might have trouble sleeping because they’re worried that they have Alzheimer’s disease. Something that can push you toward FCD is when the person is exceptionally worried and much of their bandwidth is taken up by this distress around their own cognition.
Yes, yes, yes. You know, this bridge is a little bit, I want to make sure and ask the question about, you know, how this is different from malingering or like a factitious situation. If you could speak to that, I think that’d be great. Cause you know, a lot of folks have that in the back of their mind. I think this area is still kind of murky. Yeah.
love the question because if we step back to FND broadly, all of which applies to FCD fully, there’s been a lot of confusion about the difference between FND and lingering or factitious disorder. And it’s understandable because sometimes when you see these patients, so if you imagine yourself as the clinician seeing a patient, imagine you’re a movement disorder specialist and you see a patient who comes in with a tremor and it doesn’t.
Dr. Ryan Van Patten (34:46.807)
fit with Parkinson’s disease or a central tremor and you notice that when they’re distracted, their phone goes off and they’re distracted and suddenly the tremor goes away. Meanwhile, you ask them about the tremor and it gets worse. Well, that’s kind of fishy. That looks suspicious. Like, are you just putting that on? And, know, in this hypothetical patient, they could be faking, but FND in all of its mysteriousness, it’s an enigma, like you said, but FND is clearly different from fainting.
great, beautiful literature on this that shows like neural signatures, neural correlates of FND versus feigning being different. There’s all these other characteristics converging evidence on how they are truly distinct. In FND, the symptoms are experienced as involuntary. They’re genuinely experienced, even though it doesn’t always look that way to us. So that’s sort of the first point. I’m happy to talk more about some of that literature. can share readings, papers on it. It’s very…
very convincing and very good to show how they’re different. And then there’s a question of clinically how to differentiate them as sort of the next step.
Yeah, yeah, I think we can hold on the literature in the sense that I trust you and that’s really all that I needed to hear is, hey, there’s a great body of literature to show that there are you know, noticeable differences or measurable differences. I definitely want to transition and talk about the actual assessment process so that I like that segue. Yeah, how are we actually assessing all of this and testing? Let’s take a break to hear from a featured partner. Y’all know that I love therapy notes.
but I am not the only one. They have a 4.9 out of five star rating on trustpilot.com and Google, which makes them the number one rated electronic health record system available for mental health folks today. They make billing, scheduling, note taking and telehealth all incredibly easy. They also offer custom forms that you can send through the portal for all the prescribers out there. There’d be notes is proudly offering e-prescribe as well and
Dr. Jeremy Sharp (36:47.518)
Maybe the most important thing for me is that they have live telephone support seven days a week so you can actually talk to a real person in a timely manner. If you’re trying to switch from another EHR, the transition is incredibly easy. They’ll import your demographic data free of charge so you can get going right away. So if you’re curious or you want to switch or you need a new EHR, try TherapyNotes for two months, absolutely free. You can go to thetestingpsychologist.com slash
therapy notes and enter the code testing. Again, totally free, no strings attached. Check it out and see why everyone is switching to therapy notes. I’m excited to tell you about PAR’s all new PAR training platform, an elevated online learning environment with everything you need in one place. This is the new home for PAR talks webinars, many of which offer APA and NASP approved CEs.
and also houses on-demand learning tools and PAR product training resources. Best of all, is free, totally free. To learn more, visit parinc.com backslash resources backslash par dash training. All right, let’s get back to the podcast.
Yep, yeah, very good question. So it can be tricky. You have a patient in front of you and you don’t know is this for us, we’re more likely to diagnose FCD. Psychologists are less likely to be the primary person diagnosing functional seizures or movement disorders versus neurologists, for example. So imagine it’s FCD. Here’s a few signs that would point you toward malingering, something that would really get you thinking about malingering. Certainly if there is
the potential for secondary gain, external incentives, there’s litigation going on. That doesn’t mean it must be, but that we know that that makes a big difference. Another one that’s not common, but when it does happen as a strong sign, would be significantly below chance performance on a performance validity test. So I want to be careful to not compromise test security, but just generally, you could imagine if there’s a test that and
Dr. Ryan Van Patten (39:03.758)
the person’s answer is a coin flip. Like you got a 50-50 chance of getting this item right if you just guess. And there’s a lot of items like that. And by the end they get like 10 % or 20 % right or fewer. That seems like you know the right answer and you are intentionally giving the wrong answer. Even if you were totally amnestic and you were just randomly guessing true and false, would probably, so you know, that points you.
toward malingering, not FND. Admission symptoms are clearly linked to secondary gain. People with FND, including FCD, can get scores in the invalid range on performance validity tests. It’s they, quote unquote, fail PVTs at a similar rate as people with other neurological disorders like epilepsy or Parkinson’s disease. So it can happen for a variety of reasons, but it’s not higher in FND versus other conditions. On the other hand, if you have multiple
scores in the invalid range and PVTs, and there are clear external incentives that is pushing you in the direction of malingering. One more would be a marked external discrepancy. So the patient tells you, can’t remember anything. I can’t pay attention for more than 30 seconds at a time. I can’t remember a list of two items. I’m brain damaged. But you have other evidence from a loved one or documentation that
in their home environment, they’re functioning normally. Or when they’re not in front of an attorney or a clinician, then there’s no impairments. That external discrepancy, that is not like FND.
Yeah, that’s fair. That’s fair. all makes sense. From an assessment standpoint, are there tools? I’m curious about the role of, you know, what I would call like traditional neuropsych testing, you know, the cognitive measures that we typically administer. there, I mean, is there any pattern? Are there any measures that are particularly helpful here or ones that we maybe want to avoid?
Dr. Ryan Van Patten (40:56.43)
question. First thing I’ll say is I’m going to be backing off our last conversation. Certainly, performance validity tests can be helpful. They can be helpful in pretty much every evaluation, especially if you’re wondering about differentiating FND from feigning. Even if you’re not wondering about feigning, there can be other reasons why the scores are not credible that are not faking. PVTs are good to consider. Pognitive testing in FCD is a little tricky.
Sometimes I give talks on this and people are surprised. I get through almost the whole talk and I haven’t mentioned cognitive testing yet. They’re like, aren’t you a neuropsychologist? that right? Yeah. It’s not that it is unhelpful. It is that the literature on cognitive profiles and FCD specifically is very underdeveloped. Much of how we find the internal inconsistency is through interview records, behavioral observations, et cetera. With that said.
We all love the tests.
Dr. Ryan Van Patten (41:55.692)
There’s better literature on cognitive functioning, cognitive testing, and functional seizures, actually. There’s a recent meta-analysis of 35 studies of neuropsych testing performance and functional seizures, and we can generalize cautiously to FCD. And as you might expect, there’s not one clear, discrete profile. It’s a diffuse, nonspecific picture. All cognitive domains are affected, people with functional seizures, including other FNDs.
can have impairments that are seen in cognitive testing. They have lower scores than controls with moderate effect sizes, moderate to large. The domain that seems most affected is attention and processing speed. We think there could be a bottleneck there. So what we think is happening with lot of people with FND is they have a lot of interoceptive awareness. Their attention is directed toward the body, like somatic symptoms, or in the case of FCD, their attention is directed toward their
brain in the sense that they’re overthinking their own thinking. And that makes it harder to focus on external goals. And so their attention is disrupted and it leads to downstream problems elsewhere.
Yeah, I could see that. I could see that. It’s so, I mean, it seems like attention and processing speed and executive functioning are such a catchall for these things that we look at. So, but good to know I’ll take any emerging profile to help. Gotcha. So it doesn’t sound like, I mean, we can rely on cognitive testing, but it’s again, like kind of murky, kind of muddy and like you said, diffuse. So that makes me, you you mentioned this, but defaults back to the, it’s doing a really good
So.
Dr. Jeremy Sharp (43:35.278)
clinical interview and observations, which I think is, you know, these are super important in any eval. Are there things in particular that you want to highlight from the interview or observation process that we should be aware of?
Yep. So there are a few soft signs in the interview, going back to that systematic review I mentioned earlier that compared FCD to dementia. Again, don’t totally hang your hat on these, but people with FCD are more likely to attend an appointment alone, certainly compared to somebody who has severe cognitive impairment who might need a caregiver to come with them. Even better than that one is the so-called head turn.
sign. So I imagine the listeners can’t hear us, but sort of imagine that you’re doing an interview with a patient and a loved one, a spouse is with them. If it’s somebody who has dementia due to Alzheimer’s disease and you ask them a question about their recent history, what often happens is you get the head turn. Like, can you tell me, you know, what have you been up to in the past few weeks? And then you get the head turn toward the spouse. honey, what have we been doing? Because they have
They have memory problems and they don’t remember. And so there’s a lot of impoverished speech. They’re looking for help to fill in the gaps. Whereas people with FCD do not do the head turn thing. they do the like, I’m making this up, but they do the lean in thing. They’re like, yeah, let me tell you, I’ve got a list of like all the 12 examples of everything I forgot. they want to share that with you.
That’s a great example. Very, you know, a qualitative-ish example, but yeah, very telling. I like that.
Dr. Ryan Van Patten (45:11.576)
There’s a little bit from testing too. So we mentioned cognitive profiles, which is important. I want to say, know, cognitive testing can be helpful in these folks, even though it’s not developed to the point we want it to be. But behavioral observations during cognitive testing can be helpful too, because here we are testing their memory. And I promise I’m not sadistic. I don’t want to make people suffer by any means, but we can sort of elicit.
some of the worry in a very real way that exemplifies the problems a person is having. So if you’re asked them to do cognitive testing, you can get catastrophizing, you can get major performance anxiety. They might decline to do testing. If they do, they might not be able to get through it. If not that, at the very least, you tend to see a lot of self-critical comments. They might be doing okay, but major sort of seeing the automatic thoughts and the self-criticism and a cycle that’s going on.
It’s not uncommon. will vocalize that and you’ll get a sense as to, this is what’s happening in your everyday life. When you want to go to the grocery store and remember four or five items, like you melt down and you get so much anxiety, you can’t do it. That can be really helpful for treatment.
Yeah, yeah, that’s fair. With the interviewing process, again, not trying to be sadistic necessarily, but to get at this internal inconsistency or contrast and so forth, do you find yourself, I mean, is it useful to design the interview in a way or identify questions that might highlight some of those inconsistencies? I mean, are you deliberately exploring situations that might bring those to light?
more so than other interviews?
Dr. Ryan Van Patten (46:54.786)
Yeah, great question. Usually you don’t have to do a whole lot of work or be highly clever as the clinician for this to come out. Good. I mean, you know, be clever as you would, Jeremy. It was natural, no doubt. what I mean is that this usually is so, they’re wearing it on their sleeves so much that, for example, there was one study where they asked a simple question like, tell me what you’ve noticed with your thinking and memory, and then clicked to stopwatch. And they have a group of people with FCD.
and a group of people with a degenerative disease. And the people with FCD tend to talk for, and that study three times longer. If you’re like recording how long their monologue went on for with that opening question, they talks for much longer than the other group. And if, you know, we can be more granular than that, I would say, you know, ask the opening question, just be, if you’re primed for this and you know what to look for, it really helps. If there’s a particular domain of
cognitive dysfunction that they’re reporting, definitely explore it like the word finding problems. Ask about it, ask for examples, and notice, observe how the problem expresses itself when they’re talking about that problem and then what it looks like behaviorally when they’re talking about something else that can really sort of eliminate the internal inconsistency.
Yeah, yeah, that makes sense. That’s good to know as well that I’m not going to have to, you know, outsmart these patients too bad, you know. That makes me think though, something you said triggered this thought of referral question. So what are these folks typically coming in for? Is it, I mean, are they complaining, I’m guessing they’re complaining about memory issues or brain fog or whatever it may be. I guess from a clinical standpoint then, when you hear any of those presenting concerns or referral questions, is it just kind of automatic in your mind at this point?
Hey, FCD is a rule out here. need to be aware of the possib-
Dr. Ryan Van Patten (48:52.078)
Definitely. I think it’s good for it to be in the back of your mind at least. And similar to how we would, there’s sort of a decision tree going on in my mind in the background, depending on what I’m learning about the patient. For example, when I see older adults, if get a referral and the person’s and their spouse is very concerned and their family’s concerned and they have a family history of Alzheimer’s disease, Alzheimer’s disease is really front and center. If they’re 53 and they have PTSD and they just had a
TBI recently and I learned that they, even through the notes, like they are reporting that it’s a problem, but others don’t seem to be. Then I’m pushed in the direction of FCD. I really work hard to not put the card before the horse. I don’t want to just assume it’s FCD because it looks like it kind of might be, but you know, those early some of the demographic factors you’re asking about or the background factors can, you know, prime you to look out for it.
That makes sense. Yes. You know, I didn’t ask about personality testing as part of the battery, but it made me think, made me think as we discuss. Do you see a role for personality assessment in these evals?
most certainly, particularly if we’re thinking about, like broadband tests of psychopathology and personality, like MMPI or PAI, I think, I don’t want to go to Tamsin, but I think they’re underutilized by neuropsychologists broadly. think they can be very helpful, for a lot of reasons. And FND specifically, given, we haven’t really covered this, but FND generally, including FCD tends to come with a lot of comorbidities.
including mental health, comorbidities, trauma, depression, anxiety, alexithymia, somatic symptoms, dissociation. And these things can be hard to assess and those types of, you know, really well designed, thorough questionnaires can kind of peek under the rocks that we should do a thorough interview either way, but can give you more clinically actionable data. The symptom validity scales can be useful, can help for treatment planning.
Dr. Ryan Van Patten (50:59.724)
So definitely encourage considering those.
Yeah, of course. Are you aware of any research out there? Okay, if not, of course, but are you aware of any research that ties FND or FCD to different personality patterns or diagnoses?
Yeah, there’s some of all of the, if we think about personality disorders, the one that is classically tied to FND or conversion disorder would be borderline personality disorder. And I think there’s some utility in that that does come up. Those features can come up emotion dysregulation, affective instability, trouble with relationships, suicidality, all that stuff can come up. I try to be careful because borderline can have a stigma to it and
People with FND have already experienced a lot of stigma and invalidation. so certainly we, you know, I don’t overplay that, but if somebody has those types of features and is struggling with those symptoms, think a borderline, have DBT, know, dialectical behavioral therapy, that’s good, a good treatment for that. So it’s worth looking into that because it could lead to an intervention that could help.
Right, right. I think that’s a nice transition to maybe one of the last steps of this process, which is the feedback and the recommendations. And I definitely want to dive into this stuff. this seems hard. This seems really hard. It’s been hard in my limited experience. I think, like I’ve said, I usually, you know, I work with kids primarily. So it’s been more of like that.
Dr. Jeremy Sharp (52:32.078)
TikTok, like tick disorders, seizures, here are the psychogenic seizures. So I’m really curious how you talk to patients about this phenomenon.
Yeah. Yeah. Great question. And it is hard in particular because we don’t get very good training in this. You know, I didn’t. And I think everyone I’ve ever talked to, I can’t remember a conversation where somebody said, yeah, in grad school, I got trained really nicely in FND. I mean, I felt really comfortable and confident. I’ve never heard that from anyone. So it becomes a lot easier when there’s training, which I think it’s part of reason why I’m interested in this. it’s a gap.
No. No.
Dr. Ryan Van Patten (53:14.808)
for grad school internship postdoc, we should be talking about this and becoming familiar with it. And it does happen in kids. I’m primarily an adult neuropsychologist, but like you mentioned, Jeremy, it in kids. So talking to patients about it, this is super important. And a big part of the struggle that patients have had here is
that they, people haven’t believed them. They’ve heard that it’s not real. They’ve heard that they’re faking. They’ve heard, have no idea what you have. All the, all the tests are negative. So you go see that other doctor because I don’t know. that as you would imagine that stigma can be atrogenic and really weighs on people. I think it, it, it’s not as hard as it might seem to do better. I would say a psycho education that you can provide be direct. Don’t be around the bush.
but do it in a compassionate and sensitive way, be willing to listen to them can go a long way. So, in a feedback session, I encourage people to say, and you can practice, if you’re feeling bashful, like practice this. Say you have functional cognitive disorder. Sometimes clinicians feel kind of, they’re like, I don’t want the patient to be mad at me if I say they have FND, but by and large, the vast majority of people appreciate that you’re telling them what they have.
and not just what they don’t have or that, it’s this NOS thing. It’s this wastebasket category, you know, tell them, tell them you have functional cognitive disorder, say it’s very real and it’s disabling. It’s a cognitive disorder that often goes unrecognized by doctors, but a lot of other people have this. And we know you have it in part because of this inconsistency that we found in
how your cognitive symptoms look, and then provide specific examples of the internal inconsistency. This isn’t meant to be a gotcha moment. It’s not like that at all. It is to be transparent and show them what you found, how there’s dysfunction at times, but how there can be function, which can be a very hopeful message. You can get better. And it’s better news than if I were telling you you had Alzheimer’s disease. And there are these treatments.
Dr. Ryan Van Patten (55:28.418)
that can help you retrain your brain in a way. It’s not easy. You have to be patient and persevere. It takes a lot of work, but you can get better. And one other thing I’ll say is through that, try to pause and I ask them, how does that sound to you? What do you think? You disagree and give them plenty of space to talk to.
Yeah, yeah, I like that. I in the few cases I’ve had in the past, I’ve always tried to validate and just say like, hey, I know you’re not faking, you know, this is a real thing. And the good news is that it’s not the real kind of thing that’s like permanently debilitating, you know, like cognitive decline or a lifelong thing. But we know that your body is and your brain are reacting to some of these stressors and whatnot in this way.
It is truly happening, but there is hope that it doesn’t have to continue to happen, right?
sure, letting them know that there are different types of memory loss. We do this with seizures too. So describing functional seizures versus epilepsy, we would say as early as possible if you think, it might be functional seizures. Say there are different types of seizures. Some types are caused by epilepsy and some types are caused by something called functional seizures. I’m not sure which one you have. We’ll do this investigation, video EEG and try to figure out cognitive disorders, memory loss. There are different types of memory loss. Sometimes it’s Alzheimer’s disease. Sometimes it’s…
of something called functional cognitive disorder. They’re both real. They’re both in the brain. They’re just different. You know, I want to be in touch with where they’re at, but if they, I don’t want to be invalidating, but if they’re ready to hear this, I would frame it positively to say this is good news because as you referenced Jeremy, you know, this means the memory circuits in your brain are not totally shot. You don’t have a
Dr. Ryan Van Patten (57:20.93)
big lesion on your brain that we can’t do anything about. This is something that can get better.
Yeah, yeah, I like the way you frame that. I might be splitting hairs here. Feel free to tell me. So, use the word disabling. I just had a thing, I was like, is that potentially like a perpetuating factor, you know, to use a word like that. So I’m not sure if that is literally something you would say or, you know, if so, how you, how you.
That’s great. No, I love it. we do, it is important to be really thoughtful about the language. And I think this is a push-pull, kind of walking a tightrope on the one hand to share sort of my thinking behind the scenes. I want to let them know that it is real and causes problems and can be severe. It’s not sometimes patients have had the experience that it’s sort of downplay. It’s not, well, at least it’s not Parkinson’s disease. It’s not Alzheimer’s. So it’s not that bad. It’s just in your head like,
In that, that can be problematic. People feel unheard. So on the one hand, I want to say, yep, it’s real. It causes problems for people. It’s disabling. But we might think, is that the best work? The other side of that is, I don’t want to say it’s permanently disabling. I don’t want to feed into the narrative that you are disabled and will never improve. So it very much depends on my rapport with the person, where they’re at, how we might steer.
the conversation I want to lean into, yes, this is a real major problem on the one hand. At the same time, there are things you can do. There are resources to help you. People support groups, talk about some of these resources. There are treatments out there that can help that require a lot of work on your end, but you can get better. Balancing that I think is really important.
Dr. Jeremy Sharp (59:14.914)
Yeah, yeah, totally agree. We touched on treatment a little bit, but let’s flesh that out a bit. Yeah, where do we go treatment wise with these photos?
Yep. So if we think about FND generally, there are treatments primarily specific to the subtypes. So there’s specific treatments for functional seizures and for functional movement disorders that as you would imagine are sort of tailored to the presenting symptom, the functional movement disorder treatments, for example, tend to incorporate physical therapy with psychotherapy together. The seizure treatments, there’s one neurobehavioral therapy that Kurt LaFrance and others developed.
here at VA Providence where I am, that can be for epilepsy or functional seizures. So it’s very FND focused, but also seizure focused. So then functional cognitive disorder, we are a little behind the seizures and movement disorders folks in terms of the development of the treatment, but there’s a lot of great work going on. So as a few examples, there’s a trial that is ongoing using ACT, acceptance.
therapy for FCD. This is Norman Poole and others. And then a colleague of mine, Erica Cotton, taking the lead on that created an FCD workbook that we’re working on sort of getting funding for research on it. It’s modeled off of a workbook for functional seizures, but applied to functional cognitive disorder. For clinicians, there’s not yet been really solid published finished clinical trials to support these. So we can, if it’s helpful, we can talk about like what to do in the meantime.
Yeah, yeah, I think that would be helpful.
Dr. Ryan Van Patten (01:00:51.532)
Yeah. So my anticipate in the not too distant future, we will have this very packaged workbook with a clinical trial data to support it. And there’ll be, you know, it’ll be a clear referral pathway. As of right now, what I do, since we don’t have that quite yet, for example, at the VA, when I see these folks, somebody with functional cognitive disorder, they want treatment for it. What I think is the
best thing we can do right now is try to refer them to a therapist who has experience working with other patients with FND or other somatic symptom disorders that are similar like illness anxiety disorder, and then ask the therapist to tailor treatment like CBT or ACT, tailor psychotherapy to this patient’s functional cognitive symptoms, which you, the assessor,
will have characterized very thoroughly using the biopsychosocial model, the four Ps. You’ll have this great formulation about, for example, perpetuating factors that are getting in the way. So if you can find a therapist who has some experience in related areas and then talk to them, like share your formulation with them. not telling them what to do. You’re just giving ideas from the assessment and they, skilled therapist can adapt their act or whatever the therapeutic modality is, they can adapt it.
to FCD in a really helpful way using the formulation that you’ve made.
Nice, nice. Yeah, I was thinking of, of course it escapes me now, but there’s an online platform that’s really geared toward almost like chronic pain. think there’s kind of an act component to it. I thought, you know. This has been a great conversation. I mean, I know we’re starting to wind down here, but I appreciate everything you shared. I wonder, maybe we close just thinking about from your standpoint, where the field’s headed in the future, like what research is being done or needs to be done to…
Dr. Jeremy Sharp (01:02:42.136)
to help us understand this better.
Yeah, it’s a great place to end. There is plenty of work to be done, plenty of research that we need. Let’s see, I can give a few sort of quick bullet points. So I think for FCD, something we need are large prospective epidemiological studies. We don’t have a great study like that. The best estimate is that FCD occurs in about a quarter of referrals to tertiary memory disorders clinics, but that’s based on retrospective data. So really want to know in…
primary care and neuropsychology and neurology. You know, how frequent is this? If we look at FND, we think it’s, FCD is probably very common. FND is the second most common referral to neurologists based on some data. So this, there’s at least a hundred thousand, if not a few million people in the United States with FND. So FCD is probably common as well. Number two, we want to better understand the mechanisms underlying FCD, stuff like metacognition, memory perfectionism.
Osibo effects. Understanding the mechanism will drive treatment and it’ll help us differentiate FCD from stuff like cognitive symptoms due to depression, which is related, but FCD is not just someone who’s depressed and has some slow thinking. So mechanism, we need to sharpen the diagnostic criteria, probably get them in DSM-6. I think that would help for several reasons. More.
Research on cognitive test profiles and FCD, more furthering that work, differentiating FCD from neurodegenerative diseases. Good start, but there’s more we can do there. And then certainly these treatments like clinical trials for some of these really promising interventions would be great.
Dr. Jeremy Sharp (01:04:20.27)
Nice, nice. Yeah, that’s a great list. Hopefully powerful people are listening and can take some of suggestions. this has been great. I really enjoyed this conversation. It is fascinating just from a, even from a lay person standpoint, what’s happening with these folks. But when you add the clinical component, of course, it just makes it all the more interesting. So thanks for spending the time with me. I really appreciate it.
Thanks, Jeremy. I want to say it’s great to be on a podcast that I have listened to for a number of years. Great work that you do at the Testing Psychologist. I’m honored to have been a guest.
Yeah, I really appreciate that. Well, like you said at the beginning, we testing folks got to stick together and yeah, happy to partner and hope we can do it again soon. All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out. If you like what you hear on the podcast,
Definitely.
Dr. Jeremy Sharp (01:05:22.006)
I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts. And if you’re a practice owner or aspiring practice owner, I’d invite you to check out the testing psychologists mastermind groups. have mastermind groups at every stage of practice development, beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work.
and lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com slash consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.
Dr. Jeremy Sharp (01:06:25.432)
The information contained in this podcast and on the testing psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional psychological, psychiatric or medical advice, diagnosis or treatment. Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between
the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with an expertise that fits your needs.
Click here to listen instead!