COGNITIVE FUNCTION CHALLENGESIncluding Coping and Compensatory StrategiesFIBROMYALGIA & CHRONIC FATIGUE IMMUNE DYSFUNCTION SYNDROMES

Jason Nupp, Psy.D.Spalding Rehabilitation Hospital

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.

REALLY confused?

Accepting the confusion as reality...

The Biopsychosocial Model

Biological

SociologicalPsychological

FMS/CFIDS

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 DomainPainFatigueDisturbed sleep

Emotional/Cognitive DomainsDepression, anxietyCognitive impairment (decreased concentration, disorganization)Memory problems

Social DomainDisrupted family relationshipsSocial isolationDisrupted relationships with friends

Work/Activity DomainsReduced activities of daily livingReduced leisure activities/avoidance of physical activityLoss 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

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Memory Decline Mental Confusion Speech Difficulty

FMS Patients

Non-FMS Patients

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 speedSuhr, 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