by Katarina Zulak
You go to the story and forget to buy the main item you went for, even though you have a grocery list. Actually, you forget that you even made a grocery list! This is brain fog, one of the most frustrating symptoms you can face. People with fibromyalgia (FM) report a number of cognitive challenges, including difficulty focusing, trouble planning, forgetfulness, and slower mental processing. Researchers are studying brain fog in individuals with FM to pinpoint these cognitive changes, which are complex and involve multiple brain regions and functions. I have found it helpful to understand what brain function changes happen, and how they impact my daily life. It helps me to understand what specific areas I need assistance in, and release self-blame for facing these difficulties at all; it’s you illness, it’s not you. Before we go further, let’s define what brain functions we are talking about: executive functioning and working memory.
About 80%-90% of your brain function is automatic, directing unconscious physical functions like breathing, heart rate, or digestion, and basic or instinctive activities like walking. Executive functioning comprises 10-20% of brain function and is mediated primarily by the prefrontal cortex, for the most part. Executive brain function governs control of goal-directed behaviour, planning, and self-regulation, involving mental skills like concentrating, prioritizing, organizing, time management, self-monitoring, task completion, adaptable thinking, and emotional control.  As you no doubt noticed, many of these skills are negatively affected by FM. You can think of these executive function skills in two broad categories:
Executive Function In Fibromyalgia
Common brain fog symptoms that may relate to executive dysfunction include:
· Forgetfulness as well as difficulty in remembering and processing new information
· Trouble focusing, especially when there are many distractions in the environment
· A sense of mental effort or exhaustion from concentrating, planning, thinking on the fly
· Having a hard time staying organized, managing time, juggling priorities, abruptly changing plans
· Difficulty, or mental exhaustion, from following complex instructions, sequencing tasks to finish a project, multitasking, or putting abstract ideas into words.
You’ll notice that other common brain fog symptoms, like problems with word recall, or visual perception, are not on this list. That’s because they involve other brain regions that aren’t part of executive function.
Most aspects of executive function depend on working memory. Working memory is a complex cognitive system that allows us to hold small amounts of information in the mind (new information or information retrieved from long-term memory), so that we can mentally work with it. Working memory enables us to problem-solve, make to-do lists, follow instructions, mentally rearrange priorities, and adapt plans based on new information. “For example, if you’re making dinner and you want your broiled chicken to be done at the same time as a side dish, you may pull broiling times from long-term memory then look at the side-dish recipe to see when you need to start them relative to each other.” In this case, you use working memory to follow instructions in a recipe (new information) and to access long-term memory by remembering broiling times (old information), in order to put together an entire dinner.
Cognitive Changes in Fibromyalgia that Impair Executive Function and Working Memory
In order to study the impact of fibromyalgia on executive brain function, researchers asked a group of fibromyalgia patients and a group of healthy controls to complete a comprehensive series of cognitive tests.
Executive function changes were found in two areas:
Working Memory: You know how your phone will alert you that it’s time to download new updates? A similar process occurs in your brain. In fibro patients, updating was found to be significantly impaired in individuals with fibromyalgia, suggesting a ‘glitchy’ working memory that was slower to update with new information. Brain updating involves the monitoring and evaluation of new information, and permanent updating of old information, which stored in long-term memory, with new information.
Researchers in a second study found a working memory impairment in fibromyalgia related to a verbal working memory. The verbal working memory task requires a higher memory load, suggesting that, in fibromyalgia, the more you need to remember at once in order to do a task, the worse your ability to do it may become.
Inhibition: is defined as the self-regulation to overcome distractions and impulses, and control your attention, behaviour, thoughts, and emotions, in order to do what is required or appropriate. This includes control of attention, so you are able to tune out distracting background sounds or stimuli and focus on a task. Fibromyalgia patients had trouble with inhibition related to focusing despite distraction; namely, blocking out irrelevant background noise when trying to focus on completing a test. Trouble controlling emotional impulses does not appear to be a component of executive dysfunction in fibromyalgia.
Causes of Executive Dysfunction in Fibromyalgia
The best predictor of working memory problems, specifically, is sleep disturbance and fatigue (a surprise to no one with FM!). Poor sleep and fatigue were linked to verbal and spatial working memory impairments in a study. In the past, some researchers have suggested that anxiety and depression might contribute to executive dysfunction in fibromyalgia, but the majority of studies have found little evidence to support this.
Taken over by pain processing, your brain may have less energy left over for executive functioning. In fibromyalgia, brain pathways in certain brain regions, such as the prefrontal cortex and supplementary motor area, and hippocampal regions are recruited to help process the incoming flood of pain symptoms. Neuro-imaging studies show hyperactivity in the prefrontal cortex in individuals with fibromyalgia. The prefrontal cortex, along with other brain regions, is also responsible for executive functioning. In other words, the brain structures responsible for enhanced pain processing and executive functioning overlap.
With more energy being consumed by pain processing networks, there are less resources for the brain to use for executive functions, according to some experts, resulting in executive dysfunction. In previous research, the more severe a patient’s pain was, the worse their executive dysfunction was. Pain sensitivity was correlated with difficulty doing demanding working memory tasks, in a separate study.
Other researchers argue that a more likely explanation for the relationship between pain sensitivity and executive function problems are the numerous brain changes in fibromyalgia, like brain chemicals (neurotransmitters), such dopamine, which affect pain levels and cognitive abilities.
Tools To Help Executive Function Brain Fog
Pace Your Planning: Factor the energy it takes to plan, schedule, and organise into your pacing. For us, it’s mentally fatiguing to do executive tasks. The energy consumed by going to the store starts with writing the shopping list, not when you get in the car. Try not take on too much at once, you’ll only overload your working memory. Don’t over-commit to plans, new projects, or too many to-dos. That goes for your self-care routine too. Only add one new habit in at a time, not many lifestyle changes.
Limit distractions: Paying attention, starting a task, completing a task, and time management are also drains on your executive function abilities. It’s very difficult to focus and stay on task when there are distractions in your environment. Being aware of visual or auditory distractions in your environment, and taking steps to limit them, may help. Put away your phone and turn on silent or focus mode! Noise cancelling headphones, white noise machines, a ‘do not disturb’ sign on your door, or turning off TVs and screens, are all possible options to minimise distractions. Don’t focus for too long, 25 minutes at most, then rest your mind.
Write It Down: For me, out of sight is out of mind. I am a visual learner. If I need to remember a supplement in the morning, I put the bottle beside my kettle so I see it when I make tea. I need paper calendar, and visual cues, like post-it notes, to stay organized and on top of my schedule. I tried to schedule reminders in my calendar, but found I forgot to schedule the reminder, which defeated the point! You may find a reminder app or calendar function is ideal for you. Don’t rely on your memory alone.