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Lifting the Fog: Treating Cognitive Problems

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By Bruce Campbell

(Note: From the series Treating ME/CFS and Fibromyalgia.)

Most people with Chronic Fatigue Syndrome (ME/CFS) and many people with fibromyalgia experience cognitive problems, often called "brain fog" or "fibro fog."

The difficulties, which many people find very distressing, include being forgetful, feeling confused, difficulty concentrating and the inability to speak clearly.


Cognitive problems can have a variety of causes, including:

  Overexertion   Being too active, living "outside energy envelope"
  Fatigue   Hard to be alert when tired
  Over-stimulation   Sense information from multiple sources
  Multi-tasking   Doing more than one task at the same time
  Stress   Stress increases ME/CFS and FM symptoms
  Poor Sleep   Not getting restorative sleep
  Medications   Side effects include confusion


Cognitive problems are sometimes treated with stimulants, such as Provigil (modafinil) or caffeine, but these substances can produce a push/crash cycle.

In the words of one patient, "Taking stimulants is like borrowing energy you don't really have. You feel better while you're on it, but when it wears off, you crash."

This article describes 14 non-drug strategies for lifting the fog, divided into three categories.

1) Pacing

Take a Rest Break
Cognitive difficulties can be caused by overactivity. As one person in our program said, "Brain fog helps me to recognize when I'm outside my energy envelope and need a break. Even if I don't feel tired, the fact that I can't think clearly tells me that I am beyond my limit."

A brief rest may be enough to end the fog for some people. For more on the power of rest, see Nurture Yourself with Pre-Emptive Rest.

Use Routine
Reduce fog by living a predictable life with routines: doing the same things every day in the same way. For example, always put your keys in your purse when you arrive home. If your fog is thickest in the morning, put out your clothes the night before.

Pick Your Best Time of Day
Most of us have better and worse times of the day. Do the tasks that require concentration and mental clarity during the hours you are sharpest. The best time of day varies from person to person.

For many ME/CFS and FM patients, that time is mid-afternoon to early evening. Many fibromyalgia patients find mornings the best. Find the time that's best for you.

Postpone, Switch Tasks or Cancel Activities
If you're not thinking clearly, postpone jobs that are mentally challenging, switch to a simpler task or take a break. As one person in our program said, "When I'm too tired and foggy to think, I put things off until the next day and get extra rest instead."

You can also use the presence of brain fog as a signal to cut back. As another person said, "If I'm pretty far gone, that's a sign that I need to cancel some activities."

2) Simplifying

Use Lists and Other Reminders
Write out your tasks for the day on a To Do list. Use Post-It notes in prominent places to jog your memory. Use a calendar or the alarm on your watch, computer or smartphone to keep track of appointments and tell you when to do things (or to set limits and remind you to stop). 

Organize your house and possessions so that they give you built-in reminders. For example, keep your medicines where you dress, so you will see them and remember to take them when getting up in the morning and getting ready for bed at night.

Do One Thing at a Time (Avoid Multi-Tasking)
Many patients experience fog when they try to do more than one thing at a time, such as reading while watching TV or talking while fixing dinner. The solution: instead of multi-tasking, do only one thing at a time.

To avoid interruptions, teach family members to wait by saying things like, "I'm [fixing dinner, talking on the phone, etc.] right now, but I'll help you as soon as I'm done.

Avoid Over Stimulation
If you are sensitive to noise, to light or to sensory input coming from more than one source at the same time (for example, trying to have a discussion with the TV on), limit sensory input by moving to a quiet place and avoiding distractions.

Organize and De-Clutter
If you find your physical environment overwhelming, organizing your house and removing clutter can be a way to control brain fog. See the article Illness and Housekeeping.

3) Other Fog Busters

Do Something Physical
Physical activity can increase energy and clear your mind. Activity includes exercise and other things such as laughing, singing and deep breathing.

For some people, fog may be triggered by lack of nutrition. For them, eating counteracts mental fogginess.

Improve Your Sleep
The problems associated with fog are found in people who are sleep-deprived. Getting restorative sleep can help limit cognitive problems. For ideas on improving sleep, see the article Solutions for Sleep.

Control Stress
Stress can trigger or intensify brain fog. You can reduce fog by avoiding stressful situations, by learning how to relax in response to stress and by training yourself to mute the production of adrenaline.

For more, see the articles in the Stress Management archive or the chapter on controlling stress in our self-help book.

Brain fog can be frightening and embarrassing. Many people in our program have told us that they have learned to speak reassuringly or lightheartedly to themselves and to others at times when they lack mental clarity.

If thinking you have to do something leaves you flustered, try slowing down. For more on reframing, see the article Taming Stressful Thoughts.

Plan Your Response
Deal with the fact that brain fog is confusing by planning your response ahead of time. Develop rules to guide you when you're feeling lost, so you have standard, habitual responses you can fall back on. For example, you might decide that you will respond to fog by lying down or by changing to a simpler task.

Do a Medication Check
Confusion can be a side effect of some medications. If you think this might apply to you, check with your physician about adjusting the dosage levels of your medications or changing to other drugs. Also, discuss with your doctor the use of medications to increase attention and concentration.

Multiple Strategies

Like the other symptoms discussed in this series, brain fog is best addressed by using a combination of strategies and by developing new habits.

When we have asked people in our groups to describe what they do to combat cognitive problems, we get lists that can be ten items or longer. Here's how one person described how she handles her fog.

My brain fog is worst when I'm exhausted, so I try and stay within my energy envelope. The fog episodes have greatly diminished since I learned that. Over the last several months, I've gotten organized. Orderliness helps to prevent panic and fog.

And when I'm too tired and foggy to think, I put things off until the next day and get extra rest instead. I use self-talk too, saying "this too shall pass" or "nothing catastrophic will happen if I don't do this right now." That keeps me from going into panic mode and meltdown.

I'm mentally sharpest in the morning before I get really tired, so I schedule all my brain-heavy activities in the morning and leave the simple tasks for afternoon. I also nibble some protein every couple of hours.