by Dr. Mark J Pellegrino, MD*
April 9, 2009
 Excerpted from Dr. Pellegrino’s very popular book Fibromyalgia: Up Close and Personal.* Dr. Pellegrino has seen more than 20,000 FM patients in his practice at the Ohio Rehab Center, and has been a fibromyalgia patient himself since childhood.
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Perhaps the most frustrating complaint I hear from patients with Fibromyalgia is the fibrofog.
Unlike the pain and fatigue which are usually constant nuisances, this problem causes unpredictable difficulties with our thinking. The unpredictability is the very reason it’s most frustrating. You never know when it will strike.
Fibrofog… is the cognitive dysfunction brought on by Fibromyalgia. Its symptoms include:
• Forgetfulness
• Absentmindedness
• Concentration problems
• Confusion
• Disorientation (get lost easily)
• Difficulty finding or saying words
• Short-term memory loss
• Difficulty understanding what you’ve read
• Difficulty calculating simple math problems
• Mixing up words
• Right-left confusion
• Poor ability to give directions.
Additional cognitive symptoms with more emotional components include:
• Depression
• Irritability
• Anxiety
• Panic attacks.
Fibrofog is not a dementia or early Alzheimer’s.
We demonstrate normal learning and memory although we process information more slowly because of our Fibromyalgia.
CAUSES
Multiple factors are probably involved in causing symptoms of fibrofog.
On a hormonal level, we have lower than normal concentrations of serotonin and norepinephrine in our brains. Serotonin is important for controlling pain in our central nervous system and relaxing our brain. Norepinephrine is responsible for focusing our thoughts and helping us concentrate. A low level of these 2 hormones will increase fibrofog symptoms.
Our brain’s attention centers are overwhelmed with signals which may contribute to neurological causes of fibrofog. At the attention centers, sensory signals arrive and are relayed to different areas including centers for emotion, motor reactions, and memory.
If the attention and relay centers are continuously bombarded by pain signals, the centers may be “overwhelmed” and signals get processed more slowly or blocked, or even lost altogether. This can result in symptoms such as word-finding difficulties, inability to remember something, or delayed recall.
Pain and fatigue demand attention from our brain. Our brains continuously monitor these extra “doses” of symptoms in Fibromyalgia. This engages so much of our brain’s attention that very little attention “space” is available to allow us to process, retain and recall “routine” information.
Analogy: The Cluttered Hallway
In order to explain fibrofog to my patients, I have come up with the “cluttered hallway” analogy. Picture your brain as the upstairs of a house. In this house, the upstairs bedrooms are neat, organized, and behind closed doors. The common hallway leading to each bedroom is cluttered with laundry baskets, piles of clothing, boxes, shoes, toys, and furniture. One has to navigate the clutter in order to access a bedroom, causing some delay in reaching the door.
The person trying to get into the bedroom is like the nerve signal trying to access a memory trace.
• The person (nerve signal) climbs the steps (spinal cord) up to the second floor (brain) and is standing in the common hallway (attention center).
• The egress to the bedroom door (memory) is slowed by all the clutter (neurochemical changes from Fibromyalgia). Sometimes it seems to take forever to get to a door, and at other times the person can’t remove all the clutter to open the door in a timely manner. This leads to either delayed processing or inability to read the intended thought or memory.
• Once one gets to the bedroom door and opens it, the room (memory) is in good order and can be accessed freely. In Fibromyalgia, the bedrooms are neat. In dementia, the bedrooms would be in a disarray.
The bottom line is: Keep your bedroom clean and let’s work together on clearing the hallway.
Another Analogy: Cable Access vs. Dial-Up
To those of you who are computer literate, a simple fibrofog analogy is like having dial-up Internet service on your computer instead of cable access.
If you have Internet service through your phone line, you often experience nuisance delays, or even get “kicked off” before you can get online. Once online, the computer’s memory and web pages are in order, but you may experience long delays to access them. Sometimes the delays are so long that you get “timed out.” Signals trying to get through the phone line to retrieve web pages are like signals trying to get through our attention center to retrieve memories.
Why don’t normal people without Fibromyalgia have these delays? Because they have cable connections for their computer and their signals travel quickly without delay.
Doctors with Fibromyalgia who try to write about fibrofog analogies often make things more complicated and confuse themselves in the midst of their writing… Or whatever it was they were trying to do.
HANDLING FIBROFOG
There are a number of strategies to try to treat fibrofog. We can try to take advantage of every strategy available to keep our minds less befuddled.
Write Things Down
Write notes frequently and organize the notes. When I write material for my books I go through a routine where I jot down ideas and notes on pieces of paper and collect these papers. Then I start to organize these notes in an outline format. I think of details and let my thought processes evolve over days and weeks, while continuing to write notes and organize these notes. From there on I can write my first version of the chapter, revising and categorizing along the way.
If one writes down notes and plans his or her days, or writes down names of people met or key pieces of information for an upcoming meeting or visit, the writing preparation serves two purposes.
• First, the writing actually reinforces what you are trying to remember. When you write something down you are delivering information via a different pathway to the brain and make it easier to remember by just “thinking it.”
• Second, when you write something down, you can allow your mind to relax and not worry about forgetting it, because you can simply refer to your written notes.
Consistent Routine
You need to consciously train yourself to follow a routine and strive for consistency. I always try to follow a specific routine. For example, my car keys can only be in three places: my pocket, on top of my desk, or on the kitchen counter. When I come home from work, I’ve trained myself to put them in those places. If I throw the keys on the bed, for example, I must consciously tell myself to stop everything and take the keys to the proper location.
I used to think “I’ll remember where they are,” but a few seconds later that memory was completely gone and later on I would spend many minutes searching for my keys.
You can train yourself to follow a consistent routine with practically everything you do, from the time you go to bed to the time you get up:
• The order in which you approach your morning routine;
• The locations where you’ve placed all your necessary items;
• The day planner that you check off as you complete different tasks, and so forth.
Once you have trained yourself, it will become automatic for you. Plus, the routine will save you a lot of time and frustration. In this case the best desired strategy is “same-old, same-old.”
Relaxation
Because we have difficulty with our attention spans and our ability to recall information, we are more prone to increased mental stress – which further contributes to mental fatigue.
Achieving a relaxation response helps to counteract episodes of fibrofog. So practice your relaxation strategies that you’ve learned. Make this routine part of your day. Many times we think our best thoughts and remember the most when we are relaxing, lying down, and trying to get to sleep.
Medicines
A number of prescribed medicines can be considered to help counteract the symptoms of fibrofog.
• Selective serotonin reuptake inhibitors (e.g., Prozac, Zoloft, Lexapro, Paxil) can work by helping to increase the serotonin level in the brain and facilitate neurobiological connections between the attention center and other brain centers.
• Medicines that include norepinephrine (Wellbutrin, for example) can help as well.
• Medicines in the central nervous system category (e.g., Cylert, Ritalin, Provigil) may also help by improving our brain alertness and attention. Any medicine strategy that helps reduce pain and improve energy level can help the fibrofog by reducing all the overwhelming signals that bombard the attention center and clutter the hallways.
Prescribed medicines can also interfere with memory, so they need to be evaluated and adjusted if they are aggravating fibrofog.
Examples of medicine categories that can affect memory include selective serotonin reuptake inhibitors, tricyclic antidepressants, muscle relaxants, beta blockers, anti-anxiety medicines, anti-seizure medicines, and other medicines that have been used in the treatment of Fibromyalgia.
Any medicine that causes sedation or fatigue has potential to aggravate Fibromyalgia as well.
Supplements
Some of the supplements that can be used to try to improve fibrofog include 5-HTP, colostrum, ginkgo biloba, and vinpocetine.
• The 5-HTP works by providing a substrate for the body to build more serotonin. [5-HTP (5-hydroxytryptophan) is a natural amino acid that represents the intermediate step between tryptophan and the important brain neurotransmitter serotonin. It is often low in FM patients.]
• Colostrum works by increasing growth hormone level, which enhances brain activity.
• Another supplement that can improve fatigue and fibrofog is ginkgo biloba. This supplement is thought to work by enhancing short and long-term memory by improving recall and retention, improving systemic blood flow, and facilitating nerve signals. A pilot study published in 2002 found that 64% reported improvement when taking a combination of ginkgo biloba and Coenzyme Q10 (CoQ10) for Fibromyalgia.(1)
• Vinpocetine (derived from periwinkle leaves) is a specific supplement that is felt to improve blood flow to the brain. Increased brain blood flow can boost glucose and oxygen use, and improve fibrofog symptoms; dosing is 10 to 30 mg a day.(2)
Don’t Be Too Hard on Yourself
We try to do the best we can with forgetfulness and fibrofog symptoms. Some people can do well with memory association tricks such as trying to associate a person’s name with a familiar object.
I think the most reliable way is to:
• Write things down,
• And know where to look for this written information.
You reinforce the memory by writing it down, and you can relax your mind better because you know where to look for this information when you need it. You give yourself “permission” to forget.
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Even though we may strive for a routine and may be successful at it, we will still forget things. We should not get mad at ourselves when this happens, and try to simply work around what we’re forgetting. Simply recognize that fibrofog is part of your Fibromyalgia and if you forget something it’s really not your fault.
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* This article is excerpted with kind permission from Chapter 24 of Dr. Pellegrino’s highly regarded book Fibromyalgia: Up Close & Personal, © Anadem Publishing, Inc. and Mark Pellegrino, MD, 2005, all rights reserved. This book may be ordered in the ProHealth.com store.
Resources:
1. “An open, pilot study to evaluate the potential benefits of coenzyme Q10 combined with ginkgo biloba extract in Fibromyalgia syndrome,” Journal of International Medical Research, Mar 2002.
2. See for example, “Effects of Vinpocetine on mitochrondrial function and neuroprotection in primary cortical neurons,” Neurochemistry International, Dec 2008.
Note: This information has not been reviewed by the FDA. It is generic and is not intended to prevent, diagnose, treat or cure any illness, condition, or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.
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