Hallucinogen persisting perception disorder (HPPD) is characterised by episodes of altered perception linked to past psychoactive drug use, accompanied by distress and functional impairment. To date, clinical characterisation has been limited in scale. Using TriNetX, a global federated health research network of electronic health records, we conducted a retrospective cohort study comparing clinical associations in individuals with HPPD versus population and psychedelic-using controls. Cumulative incidences of psychiatric and medical disorders were compared. Cox proportional hazards models assessed risk factors for developing HPPD, and odds ratios (ORs) were used to evaluate associated conditions following diagnosis. We identified 25,778 individuals diagnosed with HPPD. Prior to diagnosis, high rates of comorbidities were observed, including depressive episodes (29.2%), anxiety disorders (26.2%), chronic pain (15.9%), headache syndromes (14.7%), post-viral fatigue (12.3%), ADHD (6.6%), and fibromyalgia (6.7%). Anxiety and functional somatic syndromes were significantly more common in the HPPD group than in psychedelic-using controls (p < 0.001). Anxiety (OR 1.5) and post-viral fatigue (OR 1.9) predicted HPPD development in psychedelic users. HPPD diagnosis was associated with increased risk of subsequent functional somatic syndromes (OR 2.0) and psychiatric disorders (OR 1.4) versus psychedelic-using controls. This largest-to-date study of HPPD highlights its psychiatric and somatic complexity, with strong associations with anxiety and functional somatic syndromes. Several methodological limitations are acknowledged. Further research should explore overlapping pathophysiological mechanisms linking HPPD, visual disorders (e.g. visual snow syndrome), anxiety, and functional somatic syndromes.

Background: Functional seizures (FS) and functional motor symptoms (FMS), subtypes of functional neurological disorder, may involve distinct predisposing, precipitating, perpetuating, and triggering (PPPT) factors. This study investigated potential PPPT factors in FS and FMS separately. Methods: Two hundred participants (FS=50, FMS=50, individuals with anxiety and/or depression [CC]=50, healthy controls [HC]=50) completed an in-depth medical history interview and online questionnaires to assess self-reported potential aetiological factors including traumatic/adverse life events, alexithymia, autistic traits, psychological and physical symptoms, illness perceptions, cognitive-behavioural responses, and outcome measures of general functioning, and health-related quality-of-life (HRQoL). Outcomes: Participants with FS more frequently reported traumatic/adverse events and psychopathology (e.g., dissociation, PTSD) as illness causes/precipitating factors, and sensory symptom triggers, relative to FMS and/or CCs. In contrast, participants with FMS endorsed physical illness causes/precipitating factors, and physical activity and emotion-related symptom triggers, more frequently than FS and/or CCs. Physical and dissociative symptoms were elevated, alongside reductions in HRQoL and general functioning, in FS/FMS compared to CCs/HCs. Greater current, threatening illness-related beliefs and cognitions were disclosed in FS/FMS compared to CCs. Negative associations between HRQoL, cognitive-behavioural responses, and traumatic/adverse events were also seen in FS/FMS. Interpretation: Distinct biopsychosocial factors may be involved in the development and maintenance of FS and FMS: traumatic events and psychopathology in FS, and physical illness/injury, physical functioning, and alexithymia in FMS. Unhelpful illness-related beliefs, and impacts on HRQoL and general functioning, are shared between these subtypes. The results of this study provide insight into potential subtype-specific characteristics of FS/FMS, with implications for treatment. Funding: The study is funded by an MRC Career Development Award to SP [MR/V032771/1]. This project also represents independent research part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London.

Placebo effects are among the greatest paradoxes in medical research. Although more data on placebos are available from placebo-controlled trials than on any treatment in medicine, there has been comparatively little deep interrogation of issues related to their measurement, appraisal, and interpretation. Most of the work that has been done, including that in psychiatry, is narrowly focused on strategies for mitigating placebo effects and the challenges they might pose. In this Review, paper 2 of 2 on reconceptualising placebo and nocebo effects, we shift our focus from clinical practice to clinical trials. First, we review established and emerging approaches for navigating placebo effects in randomised controlled trials. Second, we examine three major challenges in contemporary psychiatric research that have recently highlighted the topic of placebo effects: (1) blinding and expectancy in psychedelic trials, (2) large placebo responses in interventional psychiatry trials (ie, device or procedure-based therapeutics), and (3) implications of overlapping neurobiological mechanisms between placebo effects and psychiatric treatments.

Background There is evidence that the two most common subtypes of functional neurological disorder, functional seizures (FSs) and functional motor symptoms (FMDs), have differences between them beyond symptom type, creating debate as to whether they may best be considered distinct disorders. However, most research has studied FS or FMD separately, and the few studies that have directly compared them have been relatively small. We used the large TriNetX electronic health database to see whether the differences previously identified would be confirmed in a larger sample of both subtypes.Methods All cases of FMD without FS were compared with cases of FS without FMD, extracted from the TriNetX electronic health records database. Previously identified between-group differences in demographics, comorbidity, and antecedents were compared between groups.Results Over 120,000 cases of FMD and FS were extracted. They confirmed that people with FS were significantly younger and had a younger onset than those with FMD, were more likely to be Black and less likely to be Asian, and had higher rates of all comorbid mental health diagnoses, other than somatoform diagnoses, which were more common in FMD. The onset of FS was more commonly preceded by psychological injury, as measured by preceding depression or stress reactions.Conclusion The differences between FMD and FS previously identified in small studies were confirmed in this much larger dataset. They provide indirect support for differences in etiology and mechanism, which may in turn support a nosological distinction between FMD and FS.

In psychiatry and medicine, there is a long history of framing placebo effects primarily as nuisance factors and focusing on how they should be minimised in clinical trials. However, a new view on placebo effects has emerged with advances in understanding their complex neurobiology and observations of unexpectedly large placebo responses in recent psychiatric trials. In particular, novel therapeutic device trials for depression have shown placebo-group remission rates nearing 50%. Instead of considering these studies as a failure and moving on, questions should be raised on how such responses are possible and how these effects can be harnessed for the benefit of patients. There have also been important new insights into the mechanisms of nocebo effects and analogous questions on how best to mitigate the effect of negative expectations on symptoms and medication side-effects. In this Review, paper 1 of 2 on reconceptualising placebo and nocebo effects, we discuss the rationale, strategies, and ethical considerations related to harnessing placebo effects and mitigating nocebo effects in clinical practice, including discussion of target patient populations, traditional pure and impure placebos, authorised deception, honest open-label placebo, pharmacotherapy dose reduction via conditioned placebo, nocebo education, nocebo reframing, and other ways to apply principles underlying placebo and nocebo effects, such as shifting mindsets and enhancing the therapeutic context. Lastly, we highlight the centrality of this topic to psychiatry, but explore how better understanding the interactions of mind, brain, and body—epitomised by placebo and nocebo effects—has crucial relevance across medicine.

Background Functional seizures (FS) and functional motor symptoms (FMS), subtypes of functional neurological disorder, may involve shared and distinct predisposing, precipitating, perpetuating and triggering (PPPT) factors. This study investigated potential self-reported PPPT factors in FS and FMS separately. Methods 200 participants (FS=50, FMS=50, individuals with anxiety and/or depression (clinical controls [CC]=50, healthy controls [HC]=50) completed an in-depth medical history interview and online questionnaires to assess potential aetiological factors including traumatic/adverse life events, alexithymia, autistic traits, psychological and physical symptoms, illness perceptions, cognitive-behavioural responses and outcome measures of general functioning and health-related quality of life (HRQoL). Results Participants with FS more frequently reported traumatic/adverse events and psychopathology (eg, dissociation, posttraumatic stress disorder) as possible illness causes/precipitating factors and sensory symptom triggers, relative to FMS and/or CCs. In contrast, participants with FMS endorsed physical illness causes/precipitating factors and physical activity and emotion-related symptom triggers more frequently than FS and/or CCs. Physical and dissociative symptoms were elevated, alongside reductions in HRQoL and general functioning in FS/FMS compared with CCs/HCs. Greater current, threatening illness-related beliefs/cognitions were disclosed in FS/FMS compared with CCs. Negative associations between HRQoL, cognitive-behavioural responses and traumatic/adverse events were also seen in FS/FMS. Conclusions Traumatic events and psychopathology may be more prominently involved in the development/maintenance of FS and physical illness/injury, physical functioning and alexithymia may be more central to FMS. Unhelpful illness-related beliefs and impacts on HRQoL and general functioning are shared between these subtypes. The results of this study provide insight into potential unique and overlapping characteristics of FS/FMS, with implications for treatment.

BACKGROUND:Cognitive symptoms are common in functional neurological disorder (FND), yet evidence of impaired neurocognitive test performance is variable. We aimed to assess self-reported cognitive symptoms, neurocognitive test performance, and metacognitive confidence in patients with functional seizures (FS) and functional motor symptoms (FMS). METHODS:Participants with FS (n = 50) and FMS (n = 50) were compared to age- and gender-matched healthy controls (HC, n = 50), and clinical controls with depression and/or anxiety disorders (CC, n = 50). The Cambridge Neuropsychological Test Automated Battery was used to examine response speed, working memory, executive functions, and social-emotional processing, with subjective confidence rated for each test. Intellectual functioning, performance validity, and self-reported cognitive symptoms were also assessed. RESULTS:The FND groups reported elevated cognitive symptoms compared to HC and CC (p-values<0.001). Impaired performance was demonstrated in both FND groups on tests of sustained attention (p-values = 0.03- < 0.001) and set-shifting (p-values = 0.01-0.001). Performance validity was comparable between groups (p = 0.64). The FND groups reported reduced post-diction confidence for sustained attention (p < 0.001). Executive performance deficits correlated with reduced test-specific confidence in FS/FMS (p-values = 0.02- < 0.001). In FMS, post-diction confidence for sustained attention performance correlated negatively with cognitive symptoms (p = 0.002). Cognitive symptoms were associated with psychological/physical symptom load, quality-of-life, and/or general functioning in FND and CC groups (p-values = 0.04- < 0.001). CONCLUSIONS:Patients with FS and FMS displayed localized deficits on tests of executive functioning, with reduced domain-specific metacognitive confidence, alongside significant cognitive symptoms. These neurocognitive features were associated with poorer clinical status, warranting interventions targeting cognitive control and/or cognitive symptoms in everyday life.

OBJECTIVE:To examine the responses of people with Functional Neurological Disorder (FND) regarding issues arising in the interpretation or application of the revised Illness Perception Questionnaire (IPQ-R). Secondly, to elicit themes relevant to understanding how people with FND conceptualise their illness. METHODS AND MEASURES:Nine participants with various FND symptoms took part in 'think-aloud' interviews whilst completing the IPQ-R. Participants' responses were examined with content and thematic analysis. RESULTS:221 issues emerged during IPQ-R completion, with the most frequent being participants' uncertainty and insufficient knowledge about FND or treatments, leading to 'I don't know' verbal comments and 'neither agree nor disagree' responses. Themes revealed 1) lack of personalised formulation, 2) significant impact of FND and comorbidities on quality of life and functioning, 3) isolation and difficulties in accessing support, and 4) nuanced ideas about the role of trauma and neurodiversity and maintaining hope. CONCLUSION:Illness perceptions in FND reflect a dynamic relationship between the complexity and uncertainty of the condition, comorbidities, stigma and treatment access difficulties. Co-produced qualitative work should explore different FND subtypes at serial timepoints in treatment to adapt the IPQ-R as a meaningful and sensitive measure for FND, which considers neurodivergent people and trauma survivors.

Acute and chronic stressors contribute to neuropsychiatric disorders. However, the role of inflammatory dynamics around stress exposure remains unclear. Using TriNetX, an international electronic health records database, we examined how systemic inflammatory activity and its temporal dynamics relate to risk of mental illness and somatic symptoms. We compared 44,904 individuals with records of accidents and leukocytosis in the surrounding period with matched individuals with normal leukocyte counts, and performed analogous comparisons for socioeconomic and psychosocial stressors in cohorts of 100,855 individuals with leukocytosis and matched controls. To contrast dynamic with static inflammatory responses, we compared cohorts exhibiting leukocyte count changes with those maintaining persistently normal or elevated counts around stressor exposure. Incidence of psychiatric and somatic symptom diagnoses were evaluated within two years of the stressor. Following acute stressors, leukocytosis (compared with normal leukocyte counts) was associated with lower rates of anxiety disorders (Odds Ratio 0.88, 95% Confidence Interval 0.83-0.93), depression (0.92, 0.86-0.98), cognitive symptoms (0.86, 0.81-0.92) and several somatic symptoms, with similar reductions in anxiety (0.92, 0.88-0.95) and depression (0.92, 0.89-0.96) observed after chronic stressors. A dynamic inflammatory response was associated with the most favourable outcomes, with lower rates of anxiety, depression, cognitive difficulties, fatigue, and pain-related symptoms compared to persistently lower or higher inflammation, and lower rates of functional neurological disorder compared to low inflammation. Our findings suggest that patterns of inflammatory response to stressors are associated with diverse mental health and somatic outcomes, with transient immune activation showing a more favourable outcome profile.

Although functional neurological disorder (FND) is common, increasingly recognized, potentially disabling, and treatable, it remains stigmatized, and concerns about feigning persist among clinicians. We examined the prevalence of malingering and factitious disorder diagnoses in individuals with FND, their associated demographic and clinical characteristics, and evidence of clinician bias in the diagnosis of feigning. In this retrospective cohort and case-control study using the international TriNetX electronic health record network, we analysed diagnostic codes (International Classification of Diseases, Tenth Revision) for FND, malingering and factitious disorder to assess their prevalence and overlap. We then compared rates of malingering and factitious disorder following a diagnosis of FND with those in cohorts of patients with multiple sclerosis and with depression, used as comparison conditions. We also examined demographic characteristics and comorbidities of FND cases with and without records of feigning, as well as temporal trends in the proportion diagnosed with malingering. Between 2015 and 2024, 143 471 individuals were diagnosed with FND, 54 685 with malingering and 5215 with factitious disorder. 2.2% of individuals with FND also received a record of malingering or, less commonly, factitious disorder, or both. Following diagnosis, FND was associated with higher rates of malingering (1.36%) and factitious disorder (0.62%) compared to multiple sclerosis (0.17%, odds ratio 7.97, 95% confidence interval 7.17–8.87; and 0.03%, odds ratio 20.47, 95% confidence interval 16.15–25.94, respectively) and depression (0.42%, odds ratio 3.23, 95% confidence interval 3.08–3.39; and 0.05%, odds ratio 12.17, 95% confidence interval 11.18–13.31, respectively). Among FND cases, factitious disorder was more prevalent in White individuals, whereas malingering was more frequent in males, Black individuals and seizure presentations. Compared to other FND cases, those with diagnoses of malingering or factitious disorder had more psychiatric, neurological, and medical comorbidities, greater socio-economic adversity and increased mortality. Records of malingering were more likely in FND cases with histories of other stigmatized disorders, such as sexually transmitted diseases, viral hepatitis and HIV. Their proportion declined from 2018 to 2023. Malingering and factitious disorder are more frequently diagnosed in FND than in comparable disorders, although both remain uncommon. Their presence is associated with greater clinical complexity and poorer outcomes. Associations with ethnicity, socio-economic adversity and certain comorbidities suggest possible clinician bias, while declining malingering diagnoses in FND may reflect growing awareness among clinicians.

In this qualitative study, we aimed to obtain and synthesise the views of patients with functional neurological disorder (FND), their caregivers, and relevant healthcare professionals (HCPs) on outcome measurement in FND. Semi-structured interviews were conducted with 22 FND patients, 18 caregivers and 21 HCPs, sampled purposively in the United Kingdom. Transcripts were analysed through inductive thematic analysis. Whilst reduction or resolution of FND symptoms were frequently mentioned as important treatment goals in all groups, this was reported by a larger proportion of caregivers and HCPs than patients. Patients most frequently hoped for improvements in mental health/well-being. Other important treatment goals were resuming work, and an increase in independence, self-management or self-efficacy. Of the 20 domains deemed relevant for outcome assessment, improvements in FND symptoms, emotional well-being, activities of daily living and quality-of-life, were mentioned most frequently. None of the participants thought that outcome assessment should be purely clinician-rated or objective; all believed that the patient’s subjective experience should be central. Nevertheless, participants in all groups acknowledged that clinician-rated or objective OMIs have added value in clinical outcome assessment. The benefits of digital outcome assessment were also mentioned by several participants. This is the first study to capture the views of key stakeholders on outcome assessment in FND. The findings indicate that outcome measures for FND should be patient-centred, whilst also including HCP opinion. Critical domains for assessment are FND symptoms, mental health, quality-of-life and the ability to perform activities of daily living.

Background:Botulism is a life-threatening neuroparalytic disease caused by botulinum neurotoxins. While its acute phase has been extensively studied, long-term sequelae following recovery remain insufficiently explored. This systematic review aims to comprehensively assess and synthesize available evidence on post-botulism sequelae to improve understanding and guide future research. Methods:A systematic search was conducted in MEDLINE, EMBASE via Ovid, and Web of Science from inception to 24 June 2024. Eligible studies included observational studies, case series, and case reports describing post-recovery symptoms in individuals diagnosed with foodborne, wound, or infant botulism, excluding iatrogenic cases. The risk of bias was assessed using the Critical Appraisal Skills Programme (CASP) checklists. Results:Out of 340 screened records, 9 studies met inclusion criteria, comprising 2 case-control studies (n = 230 botulism cases, n = 669 controls) and 7 cohort studies (n = 185 botulism cases). Most studies reported some short- and/or long-term consequences of botulism. Among 3 studies homogeneously reporting sequelae symptomatology, the most frequently reported long-term symptoms included fatigue (66.2%, range 47.9%-84.6%), limitations in vigorous activities (55.8%, range 47.6%-64.0%), general weakness (57.1%, range 43.1%-76.9%), and dyspnea (42.9%, range 18.0%-92.3%). In some patients, psychosocial dysfunction persisted longer than physical impairments, over the 6-year period post intoxication. Two studies provided comparative data with control groups, demonstrating significantly higher prevalence of fatigue, weakness, and impaired health perception in botulism survivors. Additionally, 14 case reports and case series (n = 43 individuals) reported similar patterns with dyspnea, fatigue, and autonomic dysfunction among the most reported sequelae. Conclusions:This systematic review highlights significant long-term sequelae among botulism survivors, particularly fatigue, respiratory impairment, and psychosocial dysfunction. While recovery trajectories suggest improvement over time, persistent symptoms may impact quality of life. Standardized outcome measures and longitudinal studies are needed to elucidate the burden of post-botulism sequelae further and inform clinical management strategies.

Background Functional neurological disorder (FND) is a common cause of neurological symptoms including seizures and movement disorders. It can be debilitating, is associated with high health and social care costs, and can have a poor prognosis. Functional magnetic resonance imaging (fMRI) has suggested FND is a multi-network disorder. Converging evidence suggests that other mechanisms including dissociation, interoception, and motor agency may be abnormal in people with FND. Psychedelics are currently under investigation for numerous neuropsychiatric disorders and have been shown to disrupt functional brain networks. Administering psychedelics to people with FND will help us to probe mechanistic theories of the disorder. Protocol In this open-label neuroimaging study, we will administer 25mg oral psilocybin with psychological support to people with chronic FND (target n = 24). Participants will undergo resting-state and task-based (Libet’s clock, a measure of motor agency) fMRI sequences which will be compared in a pre-post manner. Additional mechanistic outcomes including measures of interoception (heartbeat tracking task), somatisation, illness perceptions, suggestibility, and dissociation will be collected. Data on expectancy, preparedness, and subjective experience of the psychedelic experience will also be gathered. Participants will be followed up for three months following psilocybin administration. fMRI changes in networks will be analysed using seed-based approaches, and additional exploratory analysis of resting-state imaging will take place. Discussion The study will help us to probe the mechanisms thought to potentially underpin FND. As the first modern study of psychedelics in FND, it will also help us to understand whether psychedelic administration alongside psychological support might be safe and feasible in this patient population.

Background:Functional neurological disorder (FND) is a common cause of neurological symptoms including seizures and movement disorders. It can be debilitating, is associated with high health and social care costs, and can have a poor prognosis. Functional magnetic resonance imaging (fMRI) has suggested FND is a multi-network disorder. Converging evidence suggests that other mechanisms including dissociation, interoception, and motor agency may be abnormal in people with FND. Psychedelics are currently under investigation for numerous neuropsychiatric disorders and have been shown to disrupt functional brain networks. Administering psychedelics to people with FND will help us to probe mechanistic theories of the disorder. Protocol:In this open-label neuroimaging study, we will administer 25mg oral psilocybin with psychological support to people with chronic FND (target n = 24). Participants will undergo resting-state and task-based (Libet's clock, a measure of motor agency) fMRI sequences which will be compared in a pre-post manner. Additional mechanistic outcomes including measures of interoception (heartbeat tracking task), somatisation, illness perceptions, suggestibility, and dissociation will be collected. Data on expectancy, preparedness, and subjective experience of the psychedelic experience will also be gathered. Participants will be followed up for three months following psilocybin administration. fMRI changes in networks will be analysed using seed-based approaches, and additional exploratory analysis of resting-state imaging will take place. Discussion:The study will help us to probe the mechanisms thought to potentially underpin FND. As the first modern study of psychedelics in FND, it will also help us to understand whether psychedelic administration alongside psychological support might be safe and feasible in this patient population.

It is established that patients hospitalised with COVID-19 often have ongoing morbidity affecting activity of daily living (ADL), employment, and mental health. However, little is known about the relative outcomes in patients with COVID-19 neurological or psychiatric complications. We conducted a UK multicentre case-control study of patients hospitalised with COVID-19 (controls) and those who developed COVID-19 associated acute neurological or psychiatric complications (cases). Among the 651 patients, [362 (55%) cases and 289 (45%) controls], a higher proportion of cases had impairment in ADLs (199 [68.9%] vs 101 [51.8%], OR 2.06, p < 0.0002) and reported symptoms impacting employment (159 [58.2%] vs 69 [35.6%] OR 2.53, p < 0.0001). There was no significant difference in the proportion with depression or anxiety between case and control groups overall. For cases, impairment of ADLs was associated with increased risk in female sex, age > 50 years and hypertension (OR 5.43, p < 0.003, 3.11, p = 0.02, 3.66, p = 0.04). Those receiving either statins or angiotensin converting enzyme (ACE) inhibitors had a lower risk of impairment in ADLs (OR 0.09, p = 0.0006, 0.17, p = 0.03). Patients with neurological or psychiatric complications of COVID-19 had worse functional outcomes than those with respiratory COVID-19 alone in terms of ADLs and employment. Female sex, age > 50 years, and hypertension were associated with worse outcomes, and statins or ACE inhibitors with better outcomes.

Evidence is accumulating regarding an association between autism and functional neurological disorder, a common cause for a wide range of neurological symptoms affecting motor, sensory and cognitive systems. Symptoms can include paralysis, tremors, sensory disturbance, vision loss and dizziness. Functional neurological disorder exists at the complex intersection of physical and mental health, neurology and psychiatry, and body and mind. Despite a recent resurgence in clinical and scientific interest, functional neurological disorder has lagged behind other causes of neurological symptoms in research, service development and acceptance. The nature of the association between autism and functional neurological disorder remains uncertain, but several plausible mechanisms can be identified from overlapping areas of research, highlighting endogenous factors such as atypical interoception, motor function, emotional processing and sensorimotor integration, alongside exogenous influences including adversity, healthcare inequality and stigma. This review first provides an overview of functional neurological disorder through various explanatory frameworks before applying biopsychosocial, neuropsychological and computational perspectives to conceptualise its intersection with autism. It then considers how this association might be understood and explores how services could be adapted to better recognise and support autistic individuals with functional neurological disorder across the diagnostic and treatment pathway.Lay AbstractFunctional neurological disorder causes real and often disabling symptoms, such as seizures, paralysis, tremors or sensory changes, even though standard medical tests do not show physical damage to the nervous system. Research suggests that autistic people are more likely to experience functional neurological disorder than their non-autistic peers, but the reasons for this are not yet understood. This article explores why autism and functional neurological disorder might occur together. It draws on research into how the brain processes body signals (like pain or movement), handles emotions and responds to uncertainty. It also looks at life experiences that affect health, including trauma, barriers to healthcare and stigma. This article shows that both internal factors (such as differences in movement, emotional awareness and sensory processing) and external factors (such as stress, inequality and misdiagnosis) may increase the chances of functional neurological disorder in some autistic individuals. Several models are introduced to help explain how these influences might interact. Finally, this article outlines how healthcare services could better support autistic people with functional neurological disorder. It encourages functional neurological disorder services to adapt communication styles, provide appropriate adjustments and include autistic voices in research and treatment planning to improve care and outcomes.

Aims and method Neuropsychiatry training in the UK currently lacks a formal scheme or qualification, and its demand and availability have not been systematically explored. We conducted the largest UK-wide survey of psychiatry trainees to examine their experiences in neuropsychiatry training. Results In total, 185 trainees from all UK training regions completed the survey. Although 43.6% expressed interest in a neuropsychiatry career, only 10% felt they would gain sufficient experience by the end of training. Insufficient access to clinical rotations was the most common barrier, with significantly better access in London compared with other regions. Most respondents were in favour of additional neurology training (83%) and a formal accreditation in neuropsychiatry (90%). Clinical implications Strong trainee interest in neuropsychiatry contrasts with the limited training opportunities currently available nationally. Our survey highlights the need for increased neuropsychiatry training opportunities, development of a formalised training programme and a clinical accreditation pathway for neuropsychiatry in the UK.