Fibrofog, Fibromyalgia and Dissociation Understanding why some memory-impaired patients with fibromyalgia score normally on neuropsychological testing. Frank Leavitt, Ph.D. Cognitive difficulties characterized by memory lapses and mental confusion frequently disable patients with fibromyalgia from carrying out their responsibilities in the work situation, but are a challenge to prove in a disability claim. Part of the problem is that the methods of disability evaluation pertaining to cognitive complaints typically involve a referral to neuropsychologists because this group is widely considered to have specialty skills in assessing cognitive functioning. Yet, many neuropsychologists are not well versed in either the limitations of neuropsychological tests or in dissociation. Probably even fewer are cognizant of the connection between FMS, dissociation and cognitive dysfunction. More often then not, neuropsychological testing will show cognitive functioning to be normal. Normal findings shift the weight of available evidence upon entering the arena of disability determination, creating an imbalance that often enables the disability claim to be denied. However, the denial may be based on a false premise. Our clinical and research experience suggests a way of unraveling the mysterious discrepancy between patient conviction and neuropsychological findings. Instead of the flaw residing in the patient complaint, it may well be that these patients as a group are being held to the wrong standards. Testing logic often takes the following form: if memory deficits fail to be demonstrated by scores on standard measures of memory that operationally define level of impairment, then fibromyalgia patients are overestimating or overplaying the severity of their memory decline. The logic is flawed because it does not account fully for the many ways memory failures arise and overlooks shortcomings in the testing process. A process prominently linked to memory impairment is dissociation. Dissociation is a failure to integrate experiences that normally go together. Short-term memory complaints of dissociatives are well known to mimic the complaints of patients with fibromyalgia that we now refer to as fibrofog . Level of dissociation fluctuates in intensity throughout the day. Variation is likely to be influenced by daily stress. With rising intensity, sensory experience is transformed into haze like sensations leaving the patients feeling as if enveloped in a fog. At more severe intensity, lapses in memory are likely to occur leaving the individual unable to remember what was said, done or planned. But cognitive testing at levels of dissociative intensity (low) that are less apt to affect memory should yield normal performance. Normal scores on standard cognitive tests traditionally employed in neuropsychological testing can be expected among individuals experiencing dissociation for other reasons. a. Cognitive tests provide indirect information about brain function. When performance is poor, brain dysfunction is inferred. b. Memory failure for day to day events is a well-established finding with dissociation. c. Dissociation is low in patients with medically established brain damage. d. Dissociation and conditions (brain damage) wherein impaired performance is routinely observed on cognitive tests of memory are not linked or interconnected. Therefore, there is no logical reason to expect memory difficulties arising from dissociation to be associated with impaired performance on cognitive tests. Tests of dissociation are the appropriate measure for detecting memory failures arising from dissociation. Poor memory is frequently traceable to compromised attention. Impaired sensory processing of tasks involving complex stimulus sources is common in patients with fibromyalgia. The deficiencies come into play when environmental stimuli require the individual to simultaneously process information from multiple channels, activity common to real life situations, but not detectable by commonly administered measures of short-term memory. Currently available cognitive measures of short-term memory rely on selective attention to a finite set of information and are therefore suitable for assessing difficulties in only a small portion of the attention spectrum. They provide a snapshot of short term memory functioning at one point in time on tasks limited to highly focalized attention. They do not provide measures of memory under heavier processing loads requiring attention to be allocated to competing stimulus sources. The standard cognitive measures are not sensitive to complex attentional deficits and therefore can not detect or assess difficulties related to complex information processing. They can not provide a true estimate of memory when failures are secondary to impairments in processing the multiple stimuli impinging on experience at any point in time. Because of their test structure, poor attention for simple and complex stimuli will have different consequences. Poor attention for simple stimuli will adversely affect performance scores, whereas poor attention for complex stimuli will not. In sum, cognitive tests do not inform us in the same way about adults with deficits in focal attention and those with deficits in divided attention. If an individual can not focus, or frequently looses their focus, cognitive performance generally falters. By contrast, when deficits are in the area of divided attention, memory in the natural setting is readily affected by distraction, but performance does not falter on cognitive tests as long as focal attention remains intact. Thus, shortcomings inherent in the cognitive tests obscure the very problems that are salient to complaints of people with fibrofog. Collectively, findings of 3 research studies indicate that individuals with FMS are impaired for complex attention (divided attention) and normal for focal attention. Due to insensitivity to compromised attention for complex stimuli, cognitive test scores will seriously underestimate the severity of memory problems in patients whose problems arise when they must deal with many facets of a situation simultaneously. Though the combination of memory complaints and normal cognitive performance may appear paradoxical, clinicians should be cautious in their interpretations of test results. Normal performance on cognitive tests does not rule out the presence of severe and disabling memory deficits in fibromyalgia patients with fibrofog. Our research indicates that fibrofog is a subtype of fibromyalgia connected to dissociation, wherein problems with memory and mental confusion are prominent and superimposed on the primary symptoms of FMS. Individuals presenting with fibrofog exhibit a subtype of the Fibromyalgia Syndrome of a more severe form. The public perception that dissociative symptoms arise solely from psychological causation is unfounded, particularly in the case of milder forms of dissociation. Causation in many of these cases may be tied to abnormalities in N-methyl-D-aspartate receptor activity. The symptomatic difficulties that unify the fibrofog syndrome are known to be produced by sleep deprivation and certain classes of drugs that affect N-methyl-D-aspartate receptor activity. By way of illustration, Ketamine is known to induce dissociative like states in psychologically healthy individuals characterized by sensations of time slowing, alterations in sensory processing, tunnel vision, feelings of being in a fog, loss of control of thought processes and poor memory. Since Ketamine is a drug known to be mediated by the blockage of N-methyl-D-aspartate receptor activity, it is conceivable that any medical disease process that interferes with NMDA activity might induce symptoms of fibrofog in otherwise psychologically healthy individuals. For individuals with fibrofog basing a disability claim on memory decline, the dilemma posed by non-substantiating results from supposedly "objective measures of actual memory functioning" is obvious. Hopefully, the foregoing places competing claims in a better perspective for all parties participating in the disability decision. Tests covering dissociation and complex attention should come into general use in assessing these complaints. Fibrofog Reference: Cognitive and Dissociative Manifestations in Fibromyalgia Journal of Clinical Rheumatology, 2002, Volume 8. Number 2, pp:77-84.