COGNITIVE FUNCTION CHALLENGES

Including Coping and Compensatory Strategies

FIBROMYALGIA & CHRONIC FATIGUE IMMUNE DYSFUNCTION SYNDROMES

Jason Nupp, Psy.D.

Spalding Rehabilitation Hospital
Confused?
 REALLY confused?

Torpy, D., Ho, J, (2007). Corticosteroid-binding globulin gene polymorphisms: clinical implications and links to idiopathic chronic fatigue disorders .
Clinical Endocrinology 67(2): 161-167.
Accepting the confusion as reality...
 The Biopsychosocial Model
Biological

FMS/CFIDS

Psychological Sociological
Overview
 Determining What’s Wrong: Diagnosis 101
 Fibromyalgia Syndrome (FMS)

 Chronic Immune Dysfunction Syndrome (CFIDS)

 Cognitive Domains Related to FMS/CFIDS

 Perspectives From the People Who Have It (Qualitative)
 What factors affect quality of life?

 Perspectives From the People Who Study It (Quantitative)

 What does the research say?

 Possible Explanations for “Fibro Fog” and “Brain Fog”

 Biological

 Psychological

 Coping with Cognitive Challenges

 Developing Compensatory Strategies
Determining What’s Wrong: Diagnosis 101
 Fibromyalgia Syndrome (FMS)
 “ACR” Diagnostic Criteria
 Widespread pain lasting ≥ 3
months
 11 positive tender points out of
possible 18 using 4 kg of palpation
 Occiput
 Low cervical
 Trapezius
 Supraspinatus
 Second rib
 Lateral epicondyle
 Gluteal
 Greater trochanter
 Knee

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. (1990) The American College of Rheumatology 1990 criteria for the
classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 33:160–72.
 Chronic Fatigue Immune Dysfunction Syndrome (CFIDS)

 “Fukuda” Diagnostic Criteria

 Unexplained, persistent fatigue ≥
6 months that impairs daily
activity by 50%
 4 out of 8 primary signs and
symptoms
 Loss of memory or concentration
 Sore throat
 Painful and mildly enlarged lymph nodes in
neck or armpits
 Unexplained muscle pain
 Pain that moves from one joint to another
without swelling or redness
 Headache of a new type, pattern or severity
 Unrefreshing sleep
 Extreme exhaustion lasting more than 24
hours after physical or mental exercise

Fukuda K, Straus S, Hickie I, Sharpe M, Dobbins J, Komaroff A (1994). The chronic fatigue syndrome: a comprehensive approach to its definition and
study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med 121 (12): 953–9.
Cognitive Domains Related to FMS/CFIDS

 Executive Functioning (planning,

organizing, inhibition of behavior,
error detection, insight)
 Attention (focus on specific
stimuli to the relative exclusion of
others)
 Memory (encoding, recall,
recognition)
 Working Memory (temporary
storage and management of
information)
 Processing Speed (rate of
processing stimuli and making use
of it in thought and action)
Perspectives from the people who have it…
Qualitative Studies in FMS
 Arnold et al. (2008) conducted a qualitative analysis of 48
FMS patients across the U.S.

 Substantial negative impact on social and occupational

functioning

 Disrupted relationships, social isolation, reduced leisure

activities, avoidance of physical activity, and career loss or
inability to advance in career/education

Arnold, L., Crofford, L., Mease, P., Burgess, S., Palmer, S., Abetz, L., Martin, S. (2008). Patient perspectives on the impact of fibromyalgia. Patient
Education and Counseling 73: 114-120.
 Qualitative Studies in FMS
Physical Domain
Pain
Fatigue
Disturbed sleep

Emotional/Cognitive Domains
Depression, anxiety
Cognitive impairment (decreased concentration, disorganization)
Memory problems

Social Domain
Disrupted family relationships
Social isolation
Disrupted relationships with friends

Work/Activity Domains
Reduced activities of daily living
Reduced leisure activities/avoidance of physical activity
Loss of career/inability to advance in career or education
Arnold, L., Crofford, L., Mease, P., Burgess, S., Palmer, S., Abetz, L., Martin, S. (2008). Patient perspectives on the impact of fibromyalgia. Patient
Education and Counseling 73: 114-120.
Qualitative Studies in FMS
 Greatest impact on quality of life included pain, sleep
disturbance, fatigue, depression, anxiety, and cognitive
impairment
 Primary reported cognitive effects were on memory, thought
processes, planning/organization, response time, word-finding
and concentration
 These impairments have collectively been referred to by
patients as “fibro fog”
 “Fibro fog” is reported to affect a wide range of activities
including driving, social interactions, and work-related tasks

Arnold, L., Crofford, L., Mease, P., Burgess, S., Palmer, S., Abetz, L., Martin, S. (2008). Patient perspectives on the impact of fibromyalgia. Patient
Education and Counseling 73: 114-120.
Qualitative Studies in FMS
 Katz et al. (2004) investigated prevalence of reported
cognitive difficulties in 57 patients with rheumatic disease
with FMS and 57 patients without FMS
 Compared to the non-FMS sample, FMS patients more
frequently reported memory decline, mental confusion, and
speech difficulty
 Memory decline and mental confusion were coupled more
often in FMS patients
 FMS patients were found to be at considerably higher risk
for cognitive difficulty

Katz, R., Heard, A., Mills, M., Leavitt, F. (2004). The prevalence and clinical impact of reported cognitive difficulties (fibrofog) in patients with
rheumatic disease with and without fibromyalgia. Journal of Clinic Rheumatology 10(2): 53-58.
Qualitative Studies in FMS
100
90
80
70
60
50 FMS Patients
40 Non-FMS Patients
30
20
10
0
Memory Decline Mental Confusion Speech Difficulty

Katz, R., Heard, A., Mills, M., Leavitt, F. (2004). The prevalence and clinical impact of reported cognitive difficulties (fibrofog) in patients with
rheumatic disease with and without fibromyalgia. Journal of Clinic Rheumatology 10(2): 53-58.
Qualitative Studies in CFIDS
 Afari & Buchwald (2003) suggest that cognitive
problems are some of the most disruptive and
debilitating symptoms reported in patients with CFS
 85% of patients describe impairments in attention,
concentration, and memory function
 In CFS these are known as “Brain Fog”

Afari, N., Buchwald, D. (2003). Chronic Fatigue Syndrome: A Review. American Journal of Psychiatry 160: 221-236.
Qualitative Studies in CFIDS
 Capuron et al. (2006) conducted a meta-analysis
showing that 50-85% of patients with CFS report
cognitive difficulties that contribute significantly to
social and occupational dysfunction
 Cognitive dysfunction manifests primarily in the
form of concentration/attention problems, memory
impairment, poor word-finding ability, decreased
processing speed, motor slowing, and mental
exhaustion

Capuron, L., Welberg, L., Heim, C., Wagner, D., Solomon, L., Papanicolaou, D., Craddock, R., Miller, A., Reeves, W. (2006). Cognitive dysfunction
relates to subjective report of mental fatigue in patients with chronic fatigue syndrome. Neuropsychopharmacology 31:1777-1784.
Summary of Findings
 Patients with FMS and CFS report a number of
cognitive impairments referred to as “Fibro Fog”
and “Brain Fog” respectively
 These impairments include attention, memory,
executive function, processing speed, and speech
 These problems have a negative impact on daily
function including driving, social interactions, and
work tasks
Perspectives from the people who study it…
Quantitative Studies in FMS
 Suhr (2003) studied neuropsychological test performance on
28 FMS patients, 27 chronic pain patients, and 21 healthy
controls
 Measures included depression, pain, fatigue, subjective
cognitive complaints, memory, executive functioning,
intellect, attention, and psychomotor speed
 FMS patients had more memory complaints, reported greater
fatigue, pain, and depression than other groups
 Groups were not found to be different on testing after
controlling for fatigue, pain, and depression
 Depression related to memory performance
 Fatigue related to psychomotor speed
Suhr, J. (2003). Neuropsychological impairment in fibromyalgia: Relation to depression, fatigue, and pain. Journal of Psychosomatic Research
55(4): 321-329.
Quantitative Studies in FMS
 Hoover (2006) investigated neuropsychological
performance of 61 women with FMS that were age and
education-matched to 63 healthy women
 FMS patients were found to have significantly poorer
performance on some measures of executive function,
working memory, and sustained attention
 Neuropsychological measures were not found to be more
significant predictors of group membership than were
measures of symptoms relevant to FMS

Hoover, K. (2006). Neuropsychological function in Fibromyalgia. Dissertation Abstracts International: Section B: The Sciences and Engineering.
66(9-B): 5090.
Quantitative Studies in CFIDS
 Metzger et al. (2002) conducted a study examining
discrepancies between perceived and actual performance by
40 CFS patients and 40 age and education matched healthy
controls
 Performance was compared on a measure of executive
function
 After correcting for differences between groups for
depression, there were no differences found in actual
performance on the test
 CFS patients were found to consistently underestimate their
performance relative to normal performance
 Performance correlated with patient’s ratings of mental effort
and fatigue

Metzger, F., Denney, D. (2002). Patient perspectives on the impact of fibromyalgia. Patient Education and Counseling 73: 114-120.
Quantitative Studies in CFIDS
 Majer et al. (2008) examined 58 CFS patients and
104 healthy controls on neuropsychological
performance
 Controlled for major psychiatric disorders and
medications known to affect cognition
 CFS patients were found to have significantly higher
levels of impairment on tasks involving motor speed
and working memory

Majer, M., Welberg, L., Capuron, L., Miller, A., Pagnoni, G., Reeves, W. (2008). Neuropsychological performance in persons with Chronic Fatigue
Syndrome: Results from a population-based study. Psychosomatic Medicine 70: 829-836.
Summary of Findings
 Many studies have found FMS and CFS patients
exhibit deficits on neuropsychological testing
 Areas of impairment included sustained attention,
working memory, processing speed, and executive
function
 After controlling for factors such as pain,
depression, and fatigue, performance was similar to
that of healthy people
Possible Biological Explanations
 cortisol levels
 hippocampus is responsible for
memory function
 FMS patients have lower
salivary-free cortisol levels
 very low and very high cortisol
levels affect hippocampal
function
 selective effects on verbal
declarative memory, selective
attention, and divided attention

Sephton, S., Studts, J., Hoover, K., Weissbecker, I., Lynch, G., Ho, I., McGuffin, S., Salmon, P. (2003). Biological and psychological factors
associated with memory function in Fibromylagia Syndrome. Health Psychology 22(6): 592-597.
Possible Biological Explanations
 anti-68/48 kDa protein antibodies
 more common in both CFS (13.2%)
and FMS (15.6%) patients
(Nishikai, et al., 2001)
 suggests related immunological
background
 patients with antibodies presented
more frequently with hypersomnia,
short-term amnesia, and difficulty
in concentration
 may be used as a possible marker
for fatigue and cognitive problems

Nishikai, S. ,Tomomatsu, S., Hankins, R., Takagi, S., Miyachi, K., Kosaka, S., Akiya, K. (2001). Autoantibodies to a 68/48 kDa protein in chronic
fatigue syndrome and primary fibromyalgia: a possible marker for hypersomnia and cognitive disorders. Rheumatology 40: 806-810.
Possible Biological Explanations
 pain factors
 pain has been shown to correlate highly
with processing speed, working
memory, free recall, and recognition
memory (Park, et al. 2001)
 pain and weakened immunity is
associated with increased inflammatory
cytokines
 inflammatory cytokines affect appetite,
sleep, and fatigue levels
 pain affects serotonin and
norepinephrine
 pain medications (particularly opiates)
have well-known effects on cognitive
function

Park, D., Glass, J., Minear, M., Crofford, L. (2001). Cognitive function in fibromyalgia patients. Arthritis & Rheumatism 44(9): 2125-2133.
Possible Psychological Explanations
 clinical depression
 20% of FMS patients in one
sample reported clinical levels
of depression (Sephton et al.,
2003)
 correlated with immediate and
delayed verbal memory
performance in FMS
 depression in FMS and CFS
may also affect domains such as
processing speed and attention

Sephton, S., Studts, J., Hoover, K., Weissbecker, I., Lynch, G., Ho, I., McGuffin, S., Salmon, P. (2003). Biological and psychological factors
associated with memory function in Fibromylagia Syndrome. Health Psychology 22(6): 592-597.
Coping With Cognitive Challenges

The focus should be on addressing

the “whole” person, not just the
individual symptoms of FMS/CFIDS.
Medications
 NSAIDs (ibuprofen,
naproxen sodium)
 COX-2 Inhibitors (celecoxib)
 SSRIs (fluoxetine, sertraline,
escitalopram)
 NDRIs (duloxetine)
 SNRIs (milnacipran)
 TCAs (amitriptyline)
 AEDs (gabapentin,
pregabalin)
Physical Therapy
 range of motion exercises
 flexibility
 hydrotherapy
 manual therapy (e.g.
myofascial release, joint
manipulation, massage)
 gait alignment training
Psychotherapy
 Cognitive-Behavioral Therapy
(CBT)
 relaxation training
 development of coping skills
 treatment of related conditions
(e.g. depression, insomnia,
pain)
Complementary and Alternative Medicine

 biofeedback therapy
 Mindfulness-Based Stress
Reduction (MBSR)
 homeopathic approaches (e.g.
Rhus Toxicodendron)
 nutritional supplements (e.g.
magnesium)
 acupuncture
 E.T.P.S.
Developing Compensatory Strategies

Developing and implementing

compensatory strategies should
increase function and not simply
provide “symptom relief.”
Compensating Through Use of Technology

 computer-assisted cognitive rehabilitation using computer

games (e.g. BrainAge™ and HAPPYneuron™) to address
processing speed, memory, and attention
 PDAs and Smartphones to address memory and executive
function/organizational skills
 Pulse Smartpens™ to assist with memory and executive
functioning
 Speech recognition software (e.g. Dragon™) to address
fatigue related to writing and note taking
Compensating Through Lifestyle Change

 diet/nutritional changes (avoid aspartame, MSG,

caffeine, simple carbohydrates, yeast, gluten, dairy,
nightshade plants)
 regular exercise (low to moderate intensity aerobic
exercise at least 2x/week with strength training)
 maintain a regular, consistent, paced routine
(sleep/wake, meals, rest breaks)
 stress reduction (relaxation, prayer/meditation,
diaphragmatic breathing)
Compensating Through Environmental Change

 avoid cold and/or damp environments

 avoid exposure to strong odors
 create rest environments void of distractions (e.g.
silence cell phone, turn off computer etc.)
 follow principles of sleep hygiene (e.g. bedtime
rituals, bed for sleep/sex only, get up after 20 min. of
unsuccessful sleep, etc.)
 avoid overheating
 reduce exposure to fluorescent lighting
Questions & Answers