In Part II of the A Neuropsychologist Looks at ME/CFS, Dr. Lange looks at neuropsychological testing, IQ, we riff on how cognitive problems can affect how well you move, and more…See Pt. I below.
- Brain Burn, Brain Drain and Low Blood Flows: A Neurologist on ‘Cognition and Chronic Fatigue Syndrome – What Do We Know’ Part I?’
How does all this show up in cognitive testing? Again, Dr. Lange reported ‘subtle and relatively small’ problems in several areas: efficient information processing, a reduced ‘working’ memory, and problems making quick decisions, that put together can wind up causing significant problems.
The Three Major Cognitive Hits in Chronic Fatigue Syndrome
- Inefficient information processing
- Low working memory
- Reduced executive planning
Oddly enough, memory issues, which at first blush seem to be big, are not; people with ME/CFS do have the ability to remember things they’ve retained – it’s the retaining part that’s the problem.
The cognitive problems in ME/CFS mostly involve processing information – how quickly you can do it and how much you can process at a time. If you can’t process information as quickly as before, and you have a smaller working memory as well, you’re not going to be able to take in as much in as before. Basically you’re slower, and you can only handle smaller bits of information. Whereas before you could hold a paragraph in your working memory, now it may be down a sentence or two. It’s not that you don’t remember it – you never got it in in order to remember it.
It’s interesting that IQ is hardly affected in ME/CFS – you can still, given enough time, figure out problems. The problem, again, is retaining the problem in your mind long enough to be able to figure it out. Dr. Vernon noted that when she was at CDC they had trouble finding tests for the patients to fail because the patients were ‘too smart’. Dr. Lange concurred that many of her patients are above average intellectually.
At this point let’s note that no one to my knowledge has asked an ME/CFS patient to do the cognitive equivalent of a two-day repeat exercise: i.e., no one has tried to simulate a ‘working environment where mental endurance comes into play. The CDC multisite study is going to challenge ME/CFS patients with an exercise test and then measure their cognitive capabilities.
Riffing on the ‘Brain/Body’ Component in ME/CFS
Most studies (but not all) suggest that the cognitive abnormalities present in ME/CFS are relatively mild, but those tests may be missing something.
Dr. Lange noted that these deficits could affect motor functioning or movement, as well, and some studies suggest that ‘motor planning’ could be affected in CFS. Movements do not just happen – before you make a movement it’s been planned out in your brain. But what if motor planning is impaired?
The Executive Functioning/Motor Planning Connection
A cognitive process called executive functioning involved in ‘planning’ has taken a hit in ME/CFS. Executive functioning includes the ‘automatic’ functions you usually don’t think about such as driving a car, cooking a meal, putting the dishes away, using an ATM machine… and walking.
A fascinating series of recent Alzheimer’s studies suggests cognitive problems may be translating to issues with movement as well. Researchers are now thinking that slower than normal walkers may have a hidden cognitive problem, and that most cognitive tests are missing an important component: the body.
“People who are focused on cognition largely never watch people move. The tests are all done sitting down. But damage to the wiring is an important shared problem of difficulty with thinking and difficulty with moving.” Dr. Studenski
A 72 year-old woman passed a walking test with flying colors but when she was asked to count backwards while walking, her rhythmic gait collapsed. Dr. Stephanie Bridenbaugh, head of the Basel Mobility Center, said,
“She teetered and wobbled on one foot. She almost tipped to the side and she didn’t notice any of it. She was mad that she didn’t remember more numbers.”
These findings reinforce the need for patients to be tested in complex environments. People with ME/CFS may do relatively well in simple tests, but asking them to count backward from 50 while walking might get very interesting.
Dr. Lange stated that, as far as other conditions go, the deficits found in ME/CFS are relatively subtle, but they show up more when we’re doing complex tasks (including perhaps walking and talking), and, in fact, researchers are now using more and more complex tests.
The Cognition and ME/CFS Webinar
Western Researchers Missing A Key Test?
Remember the dozens of different neuropsychologists tests Dr. Vernon referred to part I of this blog. A Japanese study that found not subtle but major cognitive deficits in chronic (cognitive) fatigue syndrome suggests researchers may be missing an important test. The study – which employed a ‘dual’ test (‘Kana Pick-out Test’) which requires far more cognitive resources than a single test – found startling cognitive deficits with the worst patients exhibiting dementia and even the best scoring patients scoring far below the mean. A dual test – by taxing different parts of the brain at the same time – exposes brains which have lower levels of resources.
- Dig Deeper: Japanese Sensory Gating Study Reveals Profound Cognitive Deficits Present in Chronic Fatigue Syndrome
One wonders what kinds of environments might throw movement off in ME/CFS. High stimuli environments? How about being upset or anxious or thinking furiously? How much do these distractions affect our energy levels and ease of movement?
The Medication Cognition Hit
Many very sick patients are on numerous pain and other medications some of which can affect cognition. Dr. Vernon noted that nobody has a clue what kinds of interactions can occur between multiple drugs. Dr. Vernon has been around the medical field for quite a while, but even she was startled by how many drugs some patients were on.
Dr. Lange suggested that patients ‘ask, ask, ask’ about the potential side effects of meds. In his Ottawa talk Dr. Clauw said one of the first things he does with patients is get them off any unnecessary medications, and the guide he uses is ‘functionality’. If being on the drug has made you more functional then fine; if it hasn’t then you might consider getting off of it.
Finding the Right Neuropsychologist
The deficits in ME/CFS are rather peculiar, and because of that, standard neuropsychological testing – a foundation of disability testing – needs to be done correctly or you could blow your case. Most neuropsychologists are not up to speed on the cognitive deficits in ME/CFS. Dr. Gudrun Lange knows the right tests to use, and Dr. Cheney has used Taras Onischencko’s services in the past. If you know of an ME/CFS-knowledgeable neuropsychologist, please let us know in the comments section and we’ll build a page on them.
Good neuropsychological testing is usually quite time-consuming and expensive. Dr. Lange does a full 8-hour battery in new patients, and then a second 2-hour round of testing that focuses on ME/CFS-specific problems (i.e., processing speed, working memory, information processing). She always includes something called a Validity Indicator Profile (VIP) to establish that patients have put forth the requisite effort and to dispose of any ideas of malingering.
Evolving Brain Technology
The brain is the most complex organ in the body, and researchers have a long way to go to be able to understand it, but they are making progress. The emphasis now is to attempt to the capture the brain as it is – not as a collection of single circuits but as a highly networked organ. Imaging studies are underway, one of them in CFS, that attempt to capture the brain holistically as a collection of interconnected neural networks. The big brain initiative sponsored by the federal government will be more focused on interconnections in the brain than in the structure of the brain.
Increasing One’s Cognitive Abilities
Is it possible to increase one’s cognitive capabilities? Studies suggest that different exercises can help people with chronic illnesses reduce their brain fog and help them to think more clearly and efficiently. Much more extensive studies need to be done, but Qigong, for instance, helped improve self-reported ‘mental functioning’ in fibromyalgia.
Some studies have shown that brain games do help. Lumosity helped executive and memory skills in children with cancer, but overall the evidence is limited.
Alzheimer’s is pushing the envelope on efforts to regain one’s cognitive capabilities. From experimental drugs (MSDC-0160 – a brain glucose enhancer) to acetylcholinerase inhibitors (Donepezil, mifepristone), to nicotine receptor agonists (varenicline), to repetitive transcranial magnetic stimulation (rTMS) to nasal insulin to supplements such as resveratrol and omega three derivatives, researchers are throwing as many drugs, machines, and supplements as they can at people in the early stages of Alzheimer’s, hoping they can improve their mental functioning. This field will bear watching.
The Stress of Poor Cognition
Being unable to think as clearly as you used to can be stressful. Our working memory allows us to store enough information to stay focused and understand and complete our tasks; i.e., it allows us to ‘get into the groove’ during a task and get it done. Not being able to get ‘into the groove’ is obviously inherently frustrating.
One researcher, Elbert, noted that “If your working memory is reduced, you’ll have difficulty having a cool response—in thinking it completely through—because you don’t understand what is really going on. You’ll respond more with an angry outburst to a stressful situation. This is how humans adapt to a threatening and adverse environment.”
Those upsets, frustrations and fears that come with reduced cognition, simply take up more of the limited mental space that is available. Being able to deal with them more effectively might very well free some mental energy not just for the tasks at hand but also for things as simple as walking, moving, etc. That leads us to ways of dealing with these inevitable upsets.
Mindfulness Meditation Exercises to Improve Executive Functioning
By clearing the mind of distractions, mindfulness meditation exercises could conceivably allow scarce resources to flow to and assist with executive functioning, and possibly even increase ease of movement. Could exercise that combines meditation and movement like yoga,Tai Chi, or Qigong give movement a boost?
Some studies suggest these practices can provide some help. Meditation or mindfulness training can improve executive functioning, one of the key cognitive processes that’s gone awry in ME/CFS/FM. Mindfulness training can increase one’s working memory (ability to retain information) and improve ones ‘focused attention’. Given study evidence that brains of people with FM/ME/CFS have difficulty switching off their attention to innocuous stimuli – thus limiting their ability to fully concentrate on the task at hand – finding a way to increase ones ‘focused attention’ would be a good thing.